|
SPIKED WASHER FOR CANCELLOUS SCREW
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
SPINAL FLUID TAP DIAGNOSTIC
|
Facility
|
IP
|
$416.40
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
6162270
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$395.58 |
| Rate for Payer: Cash Price |
$249.84
|
| Rate for Payer: Cigna Commercial |
$353.94
|
| Rate for Payer: First Health Commercial |
$374.76
|
| Rate for Payer: First Health Workers Compensation |
$160.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$374.76
|
| Rate for Payer: GEHA Commercial |
$291.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$374.76
|
| Rate for Payer: Multiplan All |
$378.92
|
| Rate for Payer: OMNI Networks Commercial |
$291.48
|
| Rate for Payer: One Health Plan PPO/POS |
$374.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$395.58
|
| Rate for Payer: Three Rivers Provider Network All |
$312.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.25
|
| Rate for Payer: Zelis Auto |
$166.56
|
| Rate for Payer: Zelis Worker's Compensation |
$113.68
|
|
|
SPINAL FLUID TAP DIAGNOSTIC
|
Facility
|
OP
|
$416.40
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
6162270
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,315.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$376.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$249.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$376.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$298.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$657.58
|
| Rate for Payer: Cash Price |
$249.84
|
| Rate for Payer: Cash Price |
$249.84
|
| Rate for Payer: Cigna Commercial |
$353.94
|
| Rate for Payer: First Health Commercial |
$374.76
|
| Rate for Payer: First Health Workers Compensation |
$160.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$374.76
|
| Rate for Payer: GEHA Commercial |
$333.12
|
| Rate for Payer: GEHA Medicare |
$657.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$374.76
|
| Rate for Payer: Humana ChoiceCare |
$723.34
|
| Rate for Payer: Humana Medicare Advantage |
$657.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,104.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$304.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$657.58
|
| Rate for Payer: Multiplan All |
$378.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,117.89
|
| Rate for Payer: OMNI Networks Commercial |
$291.48
|
| Rate for Payer: One Health Plan PPO/POS |
$374.76
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$351.25
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$304.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$657.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$395.58
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,315.16
|
| Rate for Payer: Three Rivers Provider Network All |
$312.30
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$644.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$304.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$657.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.25
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$657.58
|
| Rate for Payer: Zelis Auto |
$166.56
|
| Rate for Payer: Zelis Medicare |
$558.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$789.10
|
| Rate for Payer: Zelis Worker's Compensation |
$113.68
|
|
|
SPINAL PUNCTURE LUMBAR DIAGNOSTIC
|
Facility
|
IP
|
$2,077.79
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
262270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$567.24 |
| Max. Negotiated Rate |
$1,973.90 |
| Rate for Payer: Cash Price |
$1,246.67
|
| Rate for Payer: Cigna Commercial |
$1,766.12
|
| Rate for Payer: First Health Commercial |
$1,870.01
|
| Rate for Payer: First Health Workers Compensation |
$802.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,870.01
|
| Rate for Payer: GEHA Commercial |
$1,454.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,870.01
|
| Rate for Payer: Multiplan All |
$1,890.79
|
| Rate for Payer: OMNI Networks Commercial |
$1,454.45
|
| Rate for Payer: One Health Plan PPO/POS |
$1,870.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,973.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,558.34
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,932.34
|
| Rate for Payer: Zelis Auto |
$831.12
|
| Rate for Payer: Zelis Worker's Compensation |
$567.24
|
|
|
SPINAL PUNCTURE THER DRAIN CEREBROSPINAL
|
Facility
|
OP
|
$2,326.00
|
|
| Hospital Charge Code |
8162272
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$581.50 |
| Max. Negotiated Rate |
$2,209.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,395.60
|
| Rate for Payer: Cash Price |
$1,395.60
|
| Rate for Payer: Cigna Commercial |
$1,977.10
|
| Rate for Payer: First Health Commercial |
$2,093.40
|
| Rate for Payer: First Health Workers Compensation |
$898.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,093.40
|
| Rate for Payer: GEHA Commercial |
$1,860.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,093.40
|
| Rate for Payer: Humana ChoiceCare |
$604.76
|
| Rate for Payer: Multiplan All |
$2,116.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,395.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,628.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,093.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,209.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,744.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,046.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$581.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,163.18
|
| Rate for Payer: Zelis Auto |
$930.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$635.00
|
|
|
SPINAL PUNCTURE THER DRAIN CEREBROSPINAL
|
Facility
|
IP
|
$2,326.00
|
|
| Hospital Charge Code |
8162272
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$635.00 |
| Max. Negotiated Rate |
$2,209.70 |
| Rate for Payer: Cash Price |
$1,395.60
|
| Rate for Payer: Cigna Commercial |
$1,977.10
|
| Rate for Payer: First Health Commercial |
$2,093.40
|
| Rate for Payer: First Health Workers Compensation |
$898.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,093.40
|
| Rate for Payer: GEHA Commercial |
$1,628.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,093.40
|
| Rate for Payer: Multiplan All |
$2,116.66
|
| Rate for Payer: OMNI Networks Commercial |
$1,628.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,093.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,209.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,744.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,163.18
|
| Rate for Payer: Zelis Auto |
$930.40
|
| Rate for Payer: Zelis Worker's Compensation |
$635.00
|
|
|
SPIN/BRAIN PUMP REFIL & MAIN
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT 95990
|
| Hospital Charge Code |
8595990
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$159.43 |
| Max. Negotiated Rate |
$554.80 |
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$496.40
|
| Rate for Payer: First Health Commercial |
$525.60
|
| Rate for Payer: First Health Workers Compensation |
$225.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$525.60
|
| Rate for Payer: GEHA Commercial |
$408.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$525.60
|
| Rate for Payer: Multiplan All |
$531.44
|
| Rate for Payer: OMNI Networks Commercial |
$408.80
|
| Rate for Payer: One Health Plan PPO/POS |
$525.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$554.80
|
| Rate for Payer: Three Rivers Provider Network All |
$438.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$543.12
|
| Rate for Payer: Zelis Auto |
$233.60
|
| Rate for Payer: Zelis Worker's Compensation |
$159.43
|
|
|
SPIN/BRAIN PUMP REFIL & MAIN
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT 95990
|
| Hospital Charge Code |
8595990
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$150.65 |
| Max. Negotiated Rate |
$629.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$350.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$150.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$314.95
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$496.40
|
| Rate for Payer: First Health Commercial |
$525.60
|
| Rate for Payer: First Health Workers Compensation |
$225.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$525.60
|
| Rate for Payer: GEHA Commercial |
$467.20
|
| Rate for Payer: GEHA Medicare |
$314.95
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$525.60
|
| Rate for Payer: Humana ChoiceCare |
$346.44
|
| Rate for Payer: Humana Medicare Advantage |
$314.95
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$529.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$153.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$314.95
|
| Rate for Payer: Multiplan All |
$531.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$535.41
|
| Rate for Payer: OMNI Networks Commercial |
$408.80
|
| Rate for Payer: One Health Plan PPO/POS |
$525.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$177.49
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$153.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$314.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$554.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$629.90
|
| Rate for Payer: Three Rivers Provider Network All |
$438.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$308.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$153.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$314.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$543.12
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$314.95
|
| Rate for Payer: Zelis Auto |
$233.60
|
| Rate for Payer: Zelis Medicare |
$267.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$377.94
|
| Rate for Payer: Zelis Worker's Compensation |
$159.43
|
|
|
SPINL PNCTR, THERAPEUT, FOR DRNG OF CSF
|
Facility
|
IP
|
$8,952.15
|
|
|
Service Code
|
CPT 62272
|
| Hospital Charge Code |
262272
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,443.94 |
| Max. Negotiated Rate |
$8,504.54 |
| Rate for Payer: Cash Price |
$5,371.29
|
| Rate for Payer: Cigna Commercial |
$7,609.33
|
| Rate for Payer: First Health Commercial |
$8,056.94
|
| Rate for Payer: First Health Workers Compensation |
$3,456.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,056.94
|
| Rate for Payer: GEHA Commercial |
$6,266.51
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,056.94
|
| Rate for Payer: Multiplan All |
$8,146.46
|
| Rate for Payer: OMNI Networks Commercial |
$6,266.51
|
| Rate for Payer: One Health Plan PPO/POS |
$8,056.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,504.54
|
| Rate for Payer: Three Rivers Provider Network All |
$6,714.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,325.50
|
| Rate for Payer: Zelis Auto |
$3,580.86
|
| Rate for Payer: Zelis Worker's Compensation |
$2,443.94
|
|
|
SPIRIVA INHALER (DO NOT SWALLOW CAP)
|
Facility
|
IP
|
$421.00
|
|
|
Service Code
|
NDC 00597007575
|
| Hospital Charge Code |
3300895
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.93 |
| Max. Negotiated Rate |
$399.95 |
| Rate for Payer: Cash Price |
$252.60
|
| Rate for Payer: Cigna Commercial |
$357.85
|
| Rate for Payer: First Health Commercial |
$378.90
|
| Rate for Payer: First Health Workers Compensation |
$162.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$378.90
|
| Rate for Payer: GEHA Commercial |
$294.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$378.90
|
| Rate for Payer: Multiplan All |
$383.11
|
| Rate for Payer: OMNI Networks Commercial |
$294.70
|
| Rate for Payer: One Health Plan PPO/POS |
$378.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$399.95
|
| Rate for Payer: Three Rivers Provider Network All |
$315.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$391.53
|
| Rate for Payer: Zelis Auto |
$168.40
|
| Rate for Payer: Zelis Worker's Compensation |
$114.93
|
|
|
SPIRIVA INHALER (DO NOT SWALLOW CAP)
|
Facility
|
OP
|
$421.00
|
|
|
Service Code
|
NDC 00597007575
|
| Hospital Charge Code |
3300895
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.25 |
| Max. Negotiated Rate |
$399.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$252.60
|
| Rate for Payer: Cash Price |
$252.60
|
| Rate for Payer: Cigna Commercial |
$357.85
|
| Rate for Payer: First Health Commercial |
$378.90
|
| Rate for Payer: First Health Workers Compensation |
$162.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$378.90
|
| Rate for Payer: GEHA Commercial |
$336.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$378.90
|
| Rate for Payer: Humana ChoiceCare |
$109.46
|
| Rate for Payer: Multiplan All |
$383.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$252.60
|
| Rate for Payer: OMNI Networks Commercial |
$294.70
|
| Rate for Payer: One Health Plan PPO/POS |
$378.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$399.95
|
| Rate for Payer: Three Rivers Provider Network All |
$315.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$370.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$105.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$391.53
|
| Rate for Payer: Zelis Auto |
$168.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$210.50
|
| Rate for Payer: Zelis Worker's Compensation |
$114.93
|
|
|
SPIROMETRY W/BD
|
Facility
|
OP
|
$621.00
|
|
|
Service Code
|
CPT 94060
|
| Hospital Charge Code |
4000032
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$113.28 |
| Max. Negotiated Rate |
$591.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$143.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$372.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$143.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$113.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$527.85
|
| Rate for Payer: First Health Commercial |
$558.90
|
| Rate for Payer: First Health Workers Compensation |
$239.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$558.90
|
| Rate for Payer: GEHA Commercial |
$496.80
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$558.90
|
| Rate for Payer: Humana ChoiceCare |
$325.26
|
| Rate for Payer: Humana Medicare Advantage |
$295.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$496.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$115.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$565.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$434.70
|
| Rate for Payer: One Health Plan PPO/POS |
$558.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$133.46
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$589.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$465.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Commercial |
$527.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$577.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$248.40
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$169.53
|
|
|
SPIROMETRY W/BD
|
Facility
|
IP
|
$621.00
|
|
|
Service Code
|
CPT 94060
|
| Hospital Charge Code |
4000032
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$169.53 |
| Max. Negotiated Rate |
$589.95 |
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$527.85
|
| Rate for Payer: First Health Commercial |
$558.90
|
| Rate for Payer: First Health Workers Compensation |
$239.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$558.90
|
| Rate for Payer: GEHA Commercial |
$434.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$558.90
|
| Rate for Payer: Multiplan All |
$565.11
|
| Rate for Payer: OMNI Networks Commercial |
$434.70
|
| Rate for Payer: One Health Plan PPO/POS |
$558.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$589.95
|
| Rate for Payer: Three Rivers Provider Network All |
$465.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$577.53
|
| Rate for Payer: Zelis Auto |
$248.40
|
| Rate for Payer: Zelis Worker's Compensation |
$169.53
|
|
|
SPIROMETRY W/O BD
|
Facility
|
IP
|
$682.86
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
4094010
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$186.42 |
| Max. Negotiated Rate |
$648.72 |
| Rate for Payer: Cash Price |
$409.72
|
| Rate for Payer: Cigna Commercial |
$580.43
|
| Rate for Payer: First Health Commercial |
$614.57
|
| Rate for Payer: First Health Workers Compensation |
$263.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$614.57
|
| Rate for Payer: GEHA Commercial |
$478.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$614.57
|
| Rate for Payer: Multiplan All |
$621.40
|
| Rate for Payer: OMNI Networks Commercial |
$478.00
|
| Rate for Payer: One Health Plan PPO/POS |
$614.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$648.72
|
| Rate for Payer: Three Rivers Provider Network All |
$512.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$635.06
|
| Rate for Payer: Zelis Auto |
$273.14
|
| Rate for Payer: Zelis Worker's Compensation |
$186.42
|
|
|
SPIROMETRY W/O BD
|
Facility
|
OP
|
$682.86
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
4094010
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$648.72 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$409.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$191.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$148.57
|
| Rate for Payer: Cash Price |
$409.72
|
| Rate for Payer: Cash Price |
$409.72
|
| Rate for Payer: Cigna Commercial |
$580.43
|
| Rate for Payer: First Health Commercial |
$614.57
|
| Rate for Payer: First Health Workers Compensation |
$263.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$614.57
|
| Rate for Payer: GEHA Commercial |
$546.29
|
| Rate for Payer: GEHA Medicare |
$148.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$614.57
|
| Rate for Payer: Humana ChoiceCare |
$163.43
|
| Rate for Payer: Humana Medicare Advantage |
$148.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$249.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$195.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$148.57
|
| Rate for Payer: Multiplan All |
$621.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$252.57
|
| Rate for Payer: OMNI Networks Commercial |
$478.00
|
| Rate for Payer: One Health Plan PPO/POS |
$614.57
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$225.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$195.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$148.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$648.72
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$297.14
|
| Rate for Payer: Three Rivers Provider Network All |
$512.14
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$145.60
|
| Rate for Payer: United Healthcare Commercial |
$580.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$635.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$148.57
|
| Rate for Payer: Zelis Auto |
$273.14
|
| Rate for Payer: Zelis Medicare |
$126.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.28
|
| Rate for Payer: Zelis Worker's Compensation |
$186.42
|
|
|
SPIROMETRY W/O BD LA
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
4000023
|
|
Hospital Revenue Code
|
460
|
| 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
|
|
|
SPIROMETRY W/O BD LA
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
4000023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$118.75 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$241.83
|
| 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 |
$241.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$191.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$148.57
|
| 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: GEHA Medicare |
$148.57
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$391.50
|
| Rate for Payer: Humana ChoiceCare |
$163.43
|
| Rate for Payer: Humana Medicare Advantage |
$148.57
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$249.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$195.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$148.57
|
| Rate for Payer: Multiplan All |
$395.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$252.57
|
| 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 |
$225.71
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$195.48
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$148.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$413.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$297.14
|
| Rate for Payer: Three Rivers Provider Network All |
$326.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$145.60
|
| Rate for Payer: United Healthcare Commercial |
$369.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$404.55
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$148.57
|
| Rate for Payer: Zelis Auto |
$174.00
|
| Rate for Payer: Zelis Medicare |
$126.28
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$178.28
|
| Rate for Payer: Zelis Worker's Compensation |
$118.75
|
|
|
SPIRONOLACTONE 25MG TAB
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
3300862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
SPIRONOLACTONE 25MG TAB
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
3300862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
SPLENECTOMY (SEPARATE PROCEDURE) TOTAL
|
Facility
|
OP
|
$1,410.17
|
|
|
Service Code
|
CPT 38100
|
| Hospital Charge Code |
6138100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$352.54 |
| Max. Negotiated Rate |
$3,531.37 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$846.10
|
| Rate for Payer: Cash Price |
$846.10
|
| Rate for Payer: Cash Price |
$846.10
|
| Rate for Payer: Cigna Commercial |
$1,198.64
|
| Rate for Payer: First Health Commercial |
$1,269.15
|
| Rate for Payer: First Health Workers Compensation |
$3,531.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,269.15
|
| Rate for Payer: GEHA Commercial |
$1,128.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,269.15
|
| Rate for Payer: Humana ChoiceCare |
$366.64
|
| Rate for Payer: Multiplan All |
$1,283.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$846.10
|
| Rate for Payer: OMNI Networks Commercial |
$987.12
|
| Rate for Payer: One Health Plan PPO/POS |
$1,269.15
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,339.66
|
| Rate for Payer: Three Rivers Provider Network All |
$1,057.63
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,240.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$352.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,311.46
|
| Rate for Payer: Zelis Auto |
$564.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$705.09
|
| Rate for Payer: Zelis Worker's Compensation |
$2,496.93
|
|
|
SPLENECTOMY (SEPARATE PROCEDURE) TOTAL
|
Facility
|
IP
|
$1,410.17
|
|
|
Service Code
|
CPT 38100
|
| Hospital Charge Code |
6138100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$384.98 |
| Max. Negotiated Rate |
$1,339.66 |
| Rate for Payer: Cash Price |
$846.10
|
| Rate for Payer: Cigna Commercial |
$1,198.64
|
| Rate for Payer: First Health Commercial |
$1,269.15
|
| Rate for Payer: First Health Workers Compensation |
$544.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,269.15
|
| Rate for Payer: GEHA Commercial |
$987.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,269.15
|
| Rate for Payer: Multiplan All |
$1,283.25
|
| Rate for Payer: OMNI Networks Commercial |
$987.12
|
| Rate for Payer: One Health Plan PPO/POS |
$1,269.15
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,339.66
|
| Rate for Payer: Three Rivers Provider Network All |
$1,057.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,311.46
|
| Rate for Payer: Zelis Auto |
$564.07
|
| Rate for Payer: Zelis Worker's Compensation |
$384.98
|
|
|
SPLICING OF URETERS
|
Facility
|
IP
|
$2,380.00
|
|
|
Service Code
|
CPT 50770
|
| Hospital Charge Code |
6150770
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$649.74 |
| Max. Negotiated Rate |
$2,261.00 |
| Rate for Payer: Cash Price |
$1,428.00
|
| Rate for Payer: Cigna Commercial |
$2,023.00
|
| Rate for Payer: First Health Commercial |
$2,142.00
|
| Rate for Payer: First Health Workers Compensation |
$918.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,142.00
|
| Rate for Payer: GEHA Commercial |
$1,666.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,142.00
|
| Rate for Payer: Multiplan All |
$2,165.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,666.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,142.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,261.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,785.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,213.40
|
| Rate for Payer: Zelis Auto |
$952.00
|
| Rate for Payer: Zelis Worker's Compensation |
$649.74
|
|
|
SPLICING OF URETERS
|
Facility
|
OP
|
$2,380.00
|
|
|
Service Code
|
CPT 50770
|
| Hospital Charge Code |
6150770
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$595.00 |
| Max. Negotiated Rate |
$2,261.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,428.00
|
| Rate for Payer: Cash Price |
$1,428.00
|
| Rate for Payer: Cigna Commercial |
$2,023.00
|
| Rate for Payer: First Health Commercial |
$2,142.00
|
| Rate for Payer: First Health Workers Compensation |
$918.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,142.00
|
| Rate for Payer: GEHA Commercial |
$1,904.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,142.00
|
| Rate for Payer: Humana ChoiceCare |
$618.80
|
| Rate for Payer: Multiplan All |
$2,165.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,428.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,666.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,142.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,261.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,785.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,094.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$595.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,213.40
|
| Rate for Payer: Zelis Auto |
$952.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$649.74
|
|
|
SPLINTS
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
8504570
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$121.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
SPLINTS
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT A4570
|
| Hospital Charge Code |
7204570
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$139.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Humana ChoiceCare |
$45.24
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$104.40
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$153.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$43.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
