|
SIMETHICONE 125MG
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 70000038201
|
| Hospital Charge Code |
3300825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
SIMETHICONE 125MG
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 70000038201
|
| Hospital Charge Code |
3300825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
SIMETHICONE DROPS 40MG/0.6ML
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00536130375
|
| Hospital Charge Code |
3300827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$3.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Humana ChoiceCare |
$1.04
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2.40
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SIMETHICONE DROPS 40MG/0.6ML
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00536130375
|
| Hospital Charge Code |
3300827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.40
|
| Rate for Payer: First Health Commercial |
$3.60
|
| Rate for Payer: First Health Workers Compensation |
$1.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3.60
|
| Rate for Payer: GEHA Commercial |
$2.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3.60
|
| Rate for Payer: Multiplan All |
$3.64
|
| Rate for Payer: OMNI Networks Commercial |
$2.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3.72
|
| Rate for Payer: Zelis Auto |
$1.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1.09
|
|
|
SIMPLE CYSTOMETROGRAM
|
Facility
|
OP
|
$593.00
|
|
|
Service Code
|
CPT 51725
|
| Hospital Charge Code |
23551725
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$161.89 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$355.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$242.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$230.94
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$474.40
|
| Rate for Payer: GEHA Medicare |
$230.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Humana ChoiceCare |
$254.03
|
| Rate for Payer: Humana Medicare Advantage |
$230.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$387.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$246.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$230.94
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$392.60
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$285.12
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$246.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$230.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$461.88
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$246.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$230.94
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Medicare |
$196.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$277.13
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
|
SIMPLE CYSTOMETROGRAM
|
Facility
|
IP
|
$593.00
|
|
|
Service Code
|
CPT 51725
|
| Hospital Charge Code |
23551725
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$161.89 |
| Max. Negotiated Rate |
$563.35 |
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Cigna Commercial |
$504.05
|
| Rate for Payer: First Health Commercial |
$533.70
|
| Rate for Payer: First Health Workers Compensation |
$228.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$533.70
|
| Rate for Payer: GEHA Commercial |
$415.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$533.70
|
| Rate for Payer: Multiplan All |
$539.63
|
| Rate for Payer: OMNI Networks Commercial |
$415.10
|
| Rate for Payer: One Health Plan PPO/POS |
$533.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$563.35
|
| Rate for Payer: Three Rivers Provider Network All |
$444.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$551.49
|
| Rate for Payer: Zelis Auto |
$237.20
|
| Rate for Payer: Zelis Worker's Compensation |
$161.89
|
|
|
SIMPLE CYSTOMETROGRAM
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
CPT 51725
|
| Hospital Charge Code |
6151725
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: First Health Workers Compensation |
$211.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$383.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: Zelis Auto |
$219.20
|
| Rate for Payer: Zelis Worker's Compensation |
$149.60
|
|
|
SIMPLE CYSTOMETROGRAM
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
CPT 51725
|
| Hospital Charge Code |
6151725
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$305.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$242.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$230.94
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: First Health Workers Compensation |
$211.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$438.40
|
| Rate for Payer: GEHA Medicare |
$230.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Humana ChoiceCare |
$254.03
|
| Rate for Payer: Humana Medicare Advantage |
$230.94
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$387.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$246.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$230.94
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$392.60
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$285.12
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$246.94
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$230.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$461.88
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$226.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$246.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$230.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$230.94
|
| Rate for Payer: Zelis Auto |
$219.20
|
| Rate for Payer: Zelis Medicare |
$196.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$277.13
|
| Rate for Payer: Zelis Worker's Compensation |
$149.60
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
IP
|
$784.00
|
|
| Hospital Charge Code |
8150009
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$214.03 |
| Max. Negotiated Rate |
$744.80 |
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cigna Commercial |
$666.40
|
| Rate for Payer: First Health Commercial |
$705.60
|
| Rate for Payer: First Health Workers Compensation |
$302.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$705.60
|
| Rate for Payer: GEHA Commercial |
$548.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$705.60
|
| Rate for Payer: Multiplan All |
$713.44
|
| Rate for Payer: OMNI Networks Commercial |
$548.80
|
| Rate for Payer: One Health Plan PPO/POS |
$705.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$744.80
|
| Rate for Payer: Three Rivers Provider Network All |
$588.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$729.12
|
| Rate for Payer: Zelis Auto |
$313.60
|
| Rate for Payer: Zelis Worker's Compensation |
$214.03
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
OP
|
$784.00
|
|
| Hospital Charge Code |
8150009
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$196.00 |
| Max. Negotiated Rate |
$744.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$470.40
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cigna Commercial |
$666.40
|
| Rate for Payer: First Health Commercial |
$705.60
|
| Rate for Payer: First Health Workers Compensation |
$302.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$705.60
|
| Rate for Payer: GEHA Commercial |
$627.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$705.60
|
| Rate for Payer: Humana ChoiceCare |
$203.84
|
| Rate for Payer: Multiplan All |
$713.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$470.40
|
| Rate for Payer: OMNI Networks Commercial |
$548.80
|
| Rate for Payer: One Health Plan PPO/POS |
$705.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$744.80
|
| Rate for Payer: Three Rivers Provider Network All |
$588.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$689.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$196.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$729.12
|
| Rate for Payer: Zelis Auto |
$313.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$392.00
|
| Rate for Payer: Zelis Worker's Compensation |
$214.03
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
21600173
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$108.47 |
| Max. Negotiated Rate |
$758.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$241.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$108.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$379.37
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$342.55
|
| Rate for Payer: First Health Commercial |
$362.70
|
| Rate for Payer: First Health Workers Compensation |
$155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$362.70
|
| Rate for Payer: GEHA Commercial |
$322.40
|
| Rate for Payer: GEHA Medicare |
$379.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$362.70
|
| Rate for Payer: Humana ChoiceCare |
$417.31
|
| Rate for Payer: Humana Medicare Advantage |
$379.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$637.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$110.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$379.37
|
| Rate for Payer: Multiplan All |
$366.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.93
|
| Rate for Payer: OMNI Networks Commercial |
$282.10
|
| Rate for Payer: One Health Plan PPO/POS |
$362.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$127.79
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$110.68
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$379.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$382.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$758.74
|
| Rate for Payer: Three Rivers Provider Network All |
$302.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$110.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$374.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$379.37
|
| Rate for Payer: Zelis Auto |
$161.20
|
| Rate for Payer: Zelis Medicare |
$322.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.24
|
| Rate for Payer: Zelis Worker's Compensation |
$110.02
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
21600173
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$342.55
|
| Rate for Payer: First Health Commercial |
$362.70
|
| Rate for Payer: First Health Workers Compensation |
$155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$362.70
|
| Rate for Payer: GEHA Commercial |
$282.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$362.70
|
| Rate for Payer: Multiplan All |
$366.73
|
| Rate for Payer: OMNI Networks Commercial |
$282.10
|
| Rate for Payer: One Health Plan PPO/POS |
$362.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$382.85
|
| Rate for Payer: Three Rivers Provider Network All |
$302.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$374.79
|
| Rate for Payer: Zelis Auto |
$161.20
|
| Rate for Payer: Zelis Worker's Compensation |
$110.02
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
6112016
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$342.55
|
| Rate for Payer: First Health Commercial |
$362.70
|
| Rate for Payer: First Health Workers Compensation |
$155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$362.70
|
| Rate for Payer: GEHA Commercial |
$282.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$362.70
|
| Rate for Payer: Multiplan All |
$366.73
|
| Rate for Payer: OMNI Networks Commercial |
$282.10
|
| Rate for Payer: One Health Plan PPO/POS |
$362.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$382.85
|
| Rate for Payer: Three Rivers Provider Network All |
$302.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$374.79
|
| Rate for Payer: Zelis Auto |
$161.20
|
| Rate for Payer: Zelis Worker's Compensation |
$110.02
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
6112016
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$108.47 |
| Max. Negotiated Rate |
$758.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$241.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$136.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$108.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$379.37
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$342.55
|
| Rate for Payer: First Health Commercial |
$362.70
|
| Rate for Payer: First Health Workers Compensation |
$155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$362.70
|
| Rate for Payer: GEHA Commercial |
$322.40
|
| Rate for Payer: GEHA Medicare |
$379.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$362.70
|
| Rate for Payer: Humana ChoiceCare |
$417.31
|
| Rate for Payer: Humana Medicare Advantage |
$379.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$637.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$110.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$379.37
|
| Rate for Payer: Multiplan All |
$366.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.93
|
| Rate for Payer: OMNI Networks Commercial |
$282.10
|
| Rate for Payer: One Health Plan PPO/POS |
$362.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$127.79
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$110.68
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$379.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$382.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$758.74
|
| Rate for Payer: Three Rivers Provider Network All |
$302.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$110.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$374.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$379.37
|
| Rate for Payer: Zelis Auto |
$161.20
|
| Rate for Payer: Zelis Medicare |
$322.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.24
|
| Rate for Payer: Zelis Worker's Compensation |
$110.02
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
20312011
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| 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 |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
20312011
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
21600100
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$311.88
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
7212011
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$85.14 |
| Max. Negotiated Rate |
$296.29 |
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cigna Commercial |
$265.10
|
| Rate for Payer: First Health Commercial |
$280.69
|
| Rate for Payer: First Health Workers Compensation |
$120.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.69
|
| Rate for Payer: GEHA Commercial |
$218.32
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.69
|
| Rate for Payer: Multiplan All |
$283.81
|
| Rate for Payer: OMNI Networks Commercial |
$218.32
|
| Rate for Payer: One Health Plan PPO/POS |
$280.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.29
|
| Rate for Payer: Three Rivers Provider Network All |
$233.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.05
|
| Rate for Payer: Zelis Auto |
$124.75
|
| Rate for Payer: Zelis Worker's Compensation |
$85.14
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
8150005
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.97 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$470.05
|
| Rate for Payer: First Health Commercial |
$497.70
|
| Rate for Payer: First Health Workers Compensation |
$213.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$497.70
|
| Rate for Payer: GEHA Commercial |
$387.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$497.70
|
| Rate for Payer: Multiplan All |
$503.23
|
| Rate for Payer: OMNI Networks Commercial |
$387.10
|
| Rate for Payer: One Health Plan PPO/POS |
$497.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$525.35
|
| Rate for Payer: Three Rivers Provider Network All |
$414.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$514.29
|
| Rate for Payer: Zelis Auto |
$221.20
|
| Rate for Payer: Zelis Worker's Compensation |
$150.97
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$311.88
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
8512011
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$85.14 |
| Max. Negotiated Rate |
$296.29 |
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cigna Commercial |
$265.10
|
| Rate for Payer: First Health Commercial |
$280.69
|
| Rate for Payer: First Health Workers Compensation |
$120.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.69
|
| Rate for Payer: GEHA Commercial |
$218.32
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.69
|
| Rate for Payer: Multiplan All |
$283.81
|
| Rate for Payer: OMNI Networks Commercial |
$218.32
|
| Rate for Payer: One Health Plan PPO/POS |
$280.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.29
|
| Rate for Payer: Three Rivers Provider Network All |
$233.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.05
|
| Rate for Payer: Zelis Auto |
$124.75
|
| Rate for Payer: Zelis Worker's Compensation |
$85.14
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$311.88
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
7212011
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$85.14 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cigna Commercial |
$265.10
|
| Rate for Payer: First Health Commercial |
$280.69
|
| Rate for Payer: First Health Workers Compensation |
$120.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.69
|
| Rate for Payer: GEHA Commercial |
$249.50
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.69
|
| 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 |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$283.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$218.32
|
| Rate for Payer: One Health Plan PPO/POS |
$280.69
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.29
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$233.91
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$124.75
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$85.14
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$311.88
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
8512011
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$85.14 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cash Price |
$187.13
|
| Rate for Payer: Cigna Commercial |
$265.10
|
| Rate for Payer: First Health Commercial |
$280.69
|
| Rate for Payer: First Health Workers Compensation |
$120.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.69
|
| Rate for Payer: GEHA Commercial |
$249.50
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.69
|
| 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 |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$283.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$218.32
|
| Rate for Payer: One Health Plan PPO/POS |
$280.69
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.29
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$233.91
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$124.75
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$85.14
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
6112011
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
21600100
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| 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 |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
6112011
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| 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 |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
