|
sirolimus whole blood REF716712
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
22990785
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$24.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$127.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$24.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$19.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$13.73
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cigna Commercial |
$180.20
|
| Rate for Payer: First Health Commercial |
$190.80
|
| Rate for Payer: First Health Workers Compensation |
$24.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$190.80
|
| Rate for Payer: GEHA Commercial |
$169.60
|
| Rate for Payer: GEHA Medicare |
$13.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$190.80
|
| Rate for Payer: Humana ChoiceCare |
$15.10
|
| Rate for Payer: Humana Medicare Advantage |
$13.73
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$23.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$13.73
|
| Rate for Payer: Multiplan All |
$192.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23.34
|
| Rate for Payer: OMNI Networks Commercial |
$148.40
|
| Rate for Payer: One Health Plan PPO/POS |
$190.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$23.07
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.98
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$13.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$201.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$27.46
|
| Rate for Payer: Three Rivers Provider Network All |
$159.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.46
|
| Rate for Payer: United Healthcare Commercial |
$180.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$197.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$13.73
|
| Rate for Payer: Zelis Auto |
$84.80
|
| Rate for Payer: Zelis Medicare |
$11.67
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.48
|
| Rate for Payer: Zelis Worker's Compensation |
$17.22
|
|
|
SITAGLIPTIN 50 MG TAB
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 00006011231
|
| Hospital Charge Code |
3300831
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.02 |
| Max. Negotiated Rate |
$73.15 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$65.45
|
| Rate for Payer: First Health Commercial |
$69.30
|
| Rate for Payer: First Health Workers Compensation |
$29.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$69.30
|
| Rate for Payer: GEHA Commercial |
$53.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$69.30
|
| Rate for Payer: Multiplan All |
$70.07
|
| Rate for Payer: OMNI Networks Commercial |
$53.90
|
| Rate for Payer: One Health Plan PPO/POS |
$69.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$73.15
|
| Rate for Payer: Three Rivers Provider Network All |
$57.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$71.61
|
| Rate for Payer: Zelis Auto |
$30.80
|
| Rate for Payer: Zelis Worker's Compensation |
$21.02
|
|
|
SITAGLIPTIN 50 MG TAB
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 00006011231
|
| Hospital Charge Code |
3300831
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$73.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$65.45
|
| Rate for Payer: First Health Commercial |
$69.30
|
| Rate for Payer: First Health Workers Compensation |
$29.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$69.30
|
| Rate for Payer: GEHA Commercial |
$61.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$69.30
|
| Rate for Payer: Humana ChoiceCare |
$20.02
|
| Rate for Payer: Multiplan All |
$70.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$46.20
|
| Rate for Payer: OMNI Networks Commercial |
$53.90
|
| Rate for Payer: One Health Plan PPO/POS |
$69.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$73.15
|
| Rate for Payer: Three Rivers Provider Network All |
$57.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$67.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$71.61
|
| Rate for Payer: Zelis Auto |
$30.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$38.50
|
| Rate for Payer: Zelis Worker's Compensation |
$21.02
|
|
|
sjogren ab (anti-ss-a) REF012682
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2299167
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$114.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
sjogren ab (anti-ss-a) REF012682
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2299167
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.93
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$131.20
|
| Rate for Payer: GEHA Medicare |
$17.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Humana ChoiceCare |
$19.72
|
| Rate for Payer: Humana Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.93
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.48
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.86
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.57
|
| Rate for Payer: United Healthcare Commercial |
$139.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.93
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Medicare |
$15.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.52
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
sjogren ab (anti-ss-b) REF012690
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2299168
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$114.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
sjogren ab (anti-ss-b) REF012690
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2299168
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$32.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$25.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$17.93
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cigna Commercial |
$139.40
|
| Rate for Payer: First Health Commercial |
$147.60
|
| Rate for Payer: First Health Workers Compensation |
$29.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$147.60
|
| Rate for Payer: GEHA Commercial |
$131.20
|
| Rate for Payer: GEHA Medicare |
$17.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$147.60
|
| Rate for Payer: Humana ChoiceCare |
$19.72
|
| Rate for Payer: Humana Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$30.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$26.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$17.93
|
| Rate for Payer: Multiplan All |
$149.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.48
|
| Rate for Payer: OMNI Networks Commercial |
$114.80
|
| Rate for Payer: One Health Plan PPO/POS |
$147.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$30.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$26.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$17.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$155.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$35.86
|
| Rate for Payer: Three Rivers Provider Network All |
$123.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17.57
|
| Rate for Payer: United Healthcare Commercial |
$139.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$152.52
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$17.93
|
| Rate for Payer: Zelis Auto |
$65.60
|
| Rate for Payer: Zelis Medicare |
$15.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$21.52
|
| Rate for Payer: Zelis Worker's Compensation |
$20.72
|
|
|
SKIN AND MUSCLE REPAIR FACE
|
Facility
|
OP
|
$2,030.00
|
|
|
Service Code
|
CPT 15845
|
| Hospital Charge Code |
6115845
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$554.19 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,218.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: Cigna Commercial |
$1,725.50
|
| Rate for Payer: First Health Commercial |
$1,827.00
|
| Rate for Payer: First Health Workers Compensation |
$783.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,827.00
|
| Rate for Payer: GEHA Commercial |
$1,624.00
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,827.00
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,847.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,421.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,827.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,928.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,522.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,887.90
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$812.00
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$554.19
|
|
|
SKIN AND MUSCLE REPAIR FACE
|
Facility
|
IP
|
$2,030.00
|
|
|
Service Code
|
CPT 15845
|
| Hospital Charge Code |
6115845
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$554.19 |
| Max. Negotiated Rate |
$1,928.50 |
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: Cigna Commercial |
$1,725.50
|
| Rate for Payer: First Health Commercial |
$1,827.00
|
| Rate for Payer: First Health Workers Compensation |
$783.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,827.00
|
| Rate for Payer: GEHA Commercial |
$1,421.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,827.00
|
| Rate for Payer: Multiplan All |
$1,847.30
|
| Rate for Payer: OMNI Networks Commercial |
$1,421.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,827.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,928.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,522.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,887.90
|
| Rate for Payer: Zelis Auto |
$812.00
|
| Rate for Payer: Zelis Worker's Compensation |
$554.19
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 15221
|
| Hospital Charge Code |
6115221
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$60.88 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cigna Commercial |
$189.55
|
| Rate for Payer: First Health Commercial |
$200.70
|
| Rate for Payer: First Health Workers Compensation |
$86.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$200.70
|
| Rate for Payer: GEHA Commercial |
$156.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$200.70
|
| Rate for Payer: Multiplan All |
$202.93
|
| Rate for Payer: OMNI Networks Commercial |
$156.10
|
| Rate for Payer: One Health Plan PPO/POS |
$200.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$211.85
|
| Rate for Payer: Three Rivers Provider Network All |
$167.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$207.39
|
| Rate for Payer: Zelis Auto |
$89.20
|
| Rate for Payer: Zelis Worker's Compensation |
$60.88
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
CPT 15261
|
| Hospital Charge Code |
6115261
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$118.75 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$369.75
|
| Rate for Payer: First Health Commercial |
$391.50
|
| Rate for Payer: First Health Workers Compensation |
$167.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$391.50
|
| Rate for Payer: GEHA Commercial |
$304.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$391.50
|
| Rate for Payer: Multiplan All |
$395.85
|
| Rate for Payer: OMNI Networks Commercial |
$304.50
|
| Rate for Payer: One Health Plan PPO/POS |
$391.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$413.25
|
| Rate for Payer: Three Rivers Provider Network All |
$326.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$404.55
|
| Rate for Payer: Zelis Auto |
$174.00
|
| Rate for Payer: Zelis Worker's Compensation |
$118.75
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$348.00
|
|
|
Service Code
|
CPT 15241
|
| Hospital Charge Code |
6115241
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$90.48 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$208.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$295.80
|
| Rate for Payer: First Health Commercial |
$313.20
|
| Rate for Payer: First Health Workers Compensation |
$134.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$313.20
|
| Rate for Payer: GEHA Commercial |
$278.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$313.20
|
| Rate for Payer: Humana ChoiceCare |
$90.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$316.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.80
|
| Rate for Payer: OMNI Networks Commercial |
$243.60
|
| Rate for Payer: One Health Plan PPO/POS |
$313.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$330.60
|
| Rate for Payer: Three Rivers Provider Network All |
$261.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$306.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$323.64
|
| Rate for Payer: Zelis Auto |
$139.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$174.00
|
| Rate for Payer: Zelis Worker's Compensation |
$95.00
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 15221
|
| Hospital Charge Code |
6115221
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$57.98 |
| Max. Negotiated Rate |
$448.79 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$133.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$448.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$355.53
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cigna Commercial |
$189.55
|
| Rate for Payer: First Health Commercial |
$200.70
|
| Rate for Payer: First Health Workers Compensation |
$86.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$200.70
|
| Rate for Payer: GEHA Commercial |
$178.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$200.70
|
| Rate for Payer: Humana ChoiceCare |
$57.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$362.77
|
| Rate for Payer: Multiplan All |
$202.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$133.80
|
| Rate for Payer: OMNI Networks Commercial |
$156.10
|
| Rate for Payer: One Health Plan PPO/POS |
$200.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$418.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$362.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$211.85
|
| Rate for Payer: Three Rivers Provider Network All |
$167.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$196.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$362.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$207.39
|
| Rate for Payer: Zelis Auto |
$89.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$111.50
|
| Rate for Payer: Zelis Worker's Compensation |
$60.88
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
CPT 15241
|
| Hospital Charge Code |
6115241
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$95.00 |
| Max. Negotiated Rate |
$330.60 |
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$295.80
|
| Rate for Payer: First Health Commercial |
$313.20
|
| Rate for Payer: First Health Workers Compensation |
$134.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$313.20
|
| Rate for Payer: GEHA Commercial |
$243.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$313.20
|
| Rate for Payer: Multiplan All |
$316.68
|
| Rate for Payer: OMNI Networks Commercial |
$243.60
|
| Rate for Payer: One Health Plan PPO/POS |
$313.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$330.60
|
| Rate for Payer: Three Rivers Provider Network All |
$261.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$323.64
|
| Rate for Payer: Zelis Auto |
$139.20
|
| Rate for Payer: Zelis Worker's Compensation |
$95.00
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
CPT 15261
|
| Hospital Charge Code |
6115261
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.10 |
| Max. Negotiated Rate |
$1,623.22 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$369.75
|
| Rate for Payer: First Health Commercial |
$391.50
|
| Rate for Payer: First Health Workers Compensation |
$167.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$391.50
|
| Rate for Payer: GEHA Commercial |
$348.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$391.50
|
| Rate for Payer: Humana ChoiceCare |
$113.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Multiplan All |
$395.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$261.00
|
| Rate for Payer: OMNI Networks Commercial |
$304.50
|
| Rate for Payer: One Health Plan PPO/POS |
$391.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$413.25
|
| Rate for Payer: Three Rivers Provider Network All |
$326.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$382.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$404.55
|
| Rate for Payer: Zelis Auto |
$174.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$217.50
|
| Rate for Payer: Zelis Worker's Compensation |
$118.75
|
|
|
SKIN FULL GRAFT EEN & LIPS
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
CPT 15260
|
| Hospital Charge Code |
6115260
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$477.75 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,050.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,487.50
|
| Rate for Payer: First Health Commercial |
$1,575.00
|
| Rate for Payer: First Health Workers Compensation |
$675.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,575.00
|
| Rate for Payer: GEHA Commercial |
$1,400.00
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,575.00
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,592.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,225.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,575.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,662.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,312.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,627.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$700.00
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$477.75
|
|
|
SKIN FULL GRAFT EEN & LIPS
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
CPT 15260
|
| Hospital Charge Code |
6115260
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$477.75 |
| Max. Negotiated Rate |
$1,662.50 |
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,487.50
|
| Rate for Payer: First Health Commercial |
$1,575.00
|
| Rate for Payer: First Health Workers Compensation |
$675.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,575.00
|
| Rate for Payer: GEHA Commercial |
$1,225.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,575.00
|
| Rate for Payer: Multiplan All |
$1,592.50
|
| Rate for Payer: OMNI Networks Commercial |
$1,225.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,575.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,662.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,312.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,627.50
|
| Rate for Payer: Zelis Auto |
$700.00
|
| Rate for Payer: Zelis Worker's Compensation |
$477.75
|
|
|
SKIN FULL GRAFT SCLP/ARM/LEG
|
Facility
|
OP
|
$1,252.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
6115220
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$341.80 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$751.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$751.20
|
| Rate for Payer: Cash Price |
$751.20
|
| Rate for Payer: Cigna Commercial |
$1,064.20
|
| Rate for Payer: First Health Commercial |
$1,126.80
|
| Rate for Payer: First Health Workers Compensation |
$483.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,126.80
|
| Rate for Payer: GEHA Commercial |
$1,001.60
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,126.80
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,139.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$876.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,126.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,189.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$939.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,164.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$500.80
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$341.80
|
|
|
SKIN FULL GRAFT SCLP/ARM/LEG
|
Facility
|
IP
|
$1,252.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
6115220
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$341.80 |
| Max. Negotiated Rate |
$1,189.40 |
| Rate for Payer: Cash Price |
$751.20
|
| Rate for Payer: Cigna Commercial |
$1,064.20
|
| Rate for Payer: First Health Commercial |
$1,126.80
|
| Rate for Payer: First Health Workers Compensation |
$483.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,126.80
|
| Rate for Payer: GEHA Commercial |
$876.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,126.80
|
| Rate for Payer: Multiplan All |
$1,139.32
|
| Rate for Payer: OMNI Networks Commercial |
$876.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,126.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,189.40
|
| Rate for Payer: Three Rivers Provider Network All |
$939.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,164.36
|
| Rate for Payer: Zelis Auto |
$500.80
|
| Rate for Payer: Zelis Worker's Compensation |
$341.80
|
|
|
SKIN FULL GRAFT TRUNK
|
Facility
|
OP
|
$1,372.00
|
|
|
Service Code
|
CPT 15200
|
| Hospital Charge Code |
6115200
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$823.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cigna Commercial |
$1,166.20
|
| Rate for Payer: First Health Commercial |
$1,234.80
|
| Rate for Payer: First Health Workers Compensation |
$529.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,234.80
|
| Rate for Payer: GEHA Commercial |
$1,097.60
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,234.80
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,248.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$960.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,234.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,303.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,275.96
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$548.80
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$374.56
|
|
|
SKIN FULL GRAFT TRUNK
|
Facility
|
IP
|
$1,372.00
|
|
|
Service Code
|
CPT 15200
|
| Hospital Charge Code |
6115200
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$1,303.40 |
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cigna Commercial |
$1,166.20
|
| Rate for Payer: First Health Commercial |
$1,234.80
|
| Rate for Payer: First Health Workers Compensation |
$529.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,234.80
|
| Rate for Payer: GEHA Commercial |
$960.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,234.80
|
| Rate for Payer: Multiplan All |
$1,248.52
|
| Rate for Payer: OMNI Networks Commercial |
$960.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,234.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,303.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,275.96
|
| Rate for Payer: Zelis Auto |
$548.80
|
| Rate for Payer: Zelis Worker's Compensation |
$374.56
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
CPT 15201
|
| Hospital Charge Code |
6115201
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$63.96 |
| Max. Negotiated Rate |
$1,623.22 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$209.10
|
| Rate for Payer: First Health Commercial |
$221.40
|
| Rate for Payer: First Health Workers Compensation |
$94.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$221.40
|
| Rate for Payer: GEHA Commercial |
$196.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$221.40
|
| Rate for Payer: Humana ChoiceCare |
$63.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Multiplan All |
$223.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.60
|
| Rate for Payer: OMNI Networks Commercial |
$172.20
|
| Rate for Payer: One Health Plan PPO/POS |
$221.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$233.70
|
| Rate for Payer: Three Rivers Provider Network All |
$184.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$216.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$228.78
|
| Rate for Payer: Zelis Auto |
$98.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$123.00
|
| Rate for Payer: Zelis Worker's Compensation |
$67.16
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
CPT 15201
|
| Hospital Charge Code |
6115201
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$67.16 |
| Max. Negotiated Rate |
$233.70 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cigna Commercial |
$209.10
|
| Rate for Payer: First Health Commercial |
$221.40
|
| Rate for Payer: First Health Workers Compensation |
$94.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$221.40
|
| Rate for Payer: GEHA Commercial |
$172.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$221.40
|
| Rate for Payer: Multiplan All |
$223.86
|
| Rate for Payer: OMNI Networks Commercial |
$172.20
|
| Rate for Payer: One Health Plan PPO/POS |
$221.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$233.70
|
| Rate for Payer: Three Rivers Provider Network All |
$184.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$228.78
|
| Rate for Payer: Zelis Auto |
$98.40
|
| Rate for Payer: Zelis Worker's Compensation |
$67.16
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Facility
|
OP
|
$1,629.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
6115240
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$444.72 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$977.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$977.40
|
| Rate for Payer: Cash Price |
$977.40
|
| Rate for Payer: Cigna Commercial |
$1,384.65
|
| Rate for Payer: First Health Commercial |
$1,466.10
|
| Rate for Payer: First Health Workers Compensation |
$628.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,466.10
|
| Rate for Payer: GEHA Commercial |
$1,303.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,466.10
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,482.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,140.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,466.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,547.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,221.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,514.97
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$651.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$444.72
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Facility
|
IP
|
$1,629.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
6115240
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$444.72 |
| Max. Negotiated Rate |
$1,547.55 |
| Rate for Payer: Cash Price |
$977.40
|
| Rate for Payer: Cigna Commercial |
$1,384.65
|
| Rate for Payer: First Health Commercial |
$1,466.10
|
| Rate for Payer: First Health Workers Compensation |
$628.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,466.10
|
| Rate for Payer: GEHA Commercial |
$1,140.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,466.10
|
| Rate for Payer: Multiplan All |
$1,482.39
|
| Rate for Payer: OMNI Networks Commercial |
$1,140.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,466.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,547.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,221.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,514.97
|
| Rate for Payer: Zelis Auto |
$651.60
|
| Rate for Payer: Zelis Worker's Compensation |
$444.72
|
|
