|
SRS CRAN LES SIMPLE ADDL
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
CPT 61797
|
| Hospital Charge Code |
6161797
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$164.89 |
| Max. Negotiated Rate |
$573.80 |
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Cigna Commercial |
$513.40
|
| Rate for Payer: First Health Commercial |
$543.60
|
| Rate for Payer: First Health Workers Compensation |
$233.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$543.60
|
| Rate for Payer: GEHA Commercial |
$422.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$543.60
|
| Rate for Payer: Multiplan All |
$549.64
|
| Rate for Payer: OMNI Networks Commercial |
$422.80
|
| Rate for Payer: One Health Plan PPO/POS |
$543.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$573.80
|
| Rate for Payer: Three Rivers Provider Network All |
$453.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$561.72
|
| Rate for Payer: Zelis Auto |
$241.60
|
| Rate for Payer: Zelis Worker's Compensation |
$164.89
|
|
|
ST ALT COMM TX
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 92606
|
| Hospital Charge Code |
5903042
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$37.65 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$47.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$183.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$47.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$37.65
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Humana ChoiceCare |
$79.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$38.41
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$183.00
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$44.35
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$38.41
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$268.40
|
| Rate for Payer: United Healthcare Commercial |
$259.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$152.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
ST ALT COMM TX
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 92606
|
| Hospital Charge Code |
5903042
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$83.27 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
ST APHASIA EVAL
|
Facility
|
OP
|
$544.00
|
|
|
Service Code
|
CPT 96105
|
| Hospital Charge Code |
5903038
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$69.92 |
| Max. Negotiated Rate |
$516.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$88.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$326.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$88.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$69.92
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cigna Commercial |
$462.40
|
| Rate for Payer: First Health Commercial |
$489.60
|
| Rate for Payer: First Health Workers Compensation |
$210.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$489.60
|
| Rate for Payer: GEHA Commercial |
$435.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$489.60
|
| Rate for Payer: Humana ChoiceCare |
$141.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.34
|
| Rate for Payer: Multiplan All |
$495.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$326.40
|
| Rate for Payer: OMNI Networks Commercial |
$380.80
|
| Rate for Payer: One Health Plan PPO/POS |
$489.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$82.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.34
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$516.80
|
| Rate for Payer: Three Rivers Provider Network All |
$408.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$478.72
|
| Rate for Payer: United Healthcare Commercial |
$462.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.34
|
| Rate for Payer: United Payors & United Providers UP&UP |
$505.92
|
| Rate for Payer: Zelis Auto |
$217.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$272.00
|
| Rate for Payer: Zelis Worker's Compensation |
$148.51
|
|
|
ST APHASIA EVAL
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
CPT 96105
|
| Hospital Charge Code |
5903038
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$148.51 |
| Max. Negotiated Rate |
$516.80 |
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cigna Commercial |
$462.40
|
| Rate for Payer: First Health Commercial |
$489.60
|
| Rate for Payer: First Health Workers Compensation |
$210.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$489.60
|
| Rate for Payer: GEHA Commercial |
$380.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$489.60
|
| Rate for Payer: Multiplan All |
$495.04
|
| Rate for Payer: OMNI Networks Commercial |
$380.80
|
| Rate for Payer: One Health Plan PPO/POS |
$489.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$516.80
|
| Rate for Payer: Three Rivers Provider Network All |
$408.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$505.92
|
| Rate for Payer: Zelis Auto |
$217.60
|
| Rate for Payer: Zelis Worker's Compensation |
$148.51
|
|
|
STAPLE RELOAD GREEN GST60G
|
Facility
|
IP
|
$1,297.88
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7007064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$354.32 |
| Max. Negotiated Rate |
$1,232.99 |
| Rate for Payer: Cash Price |
$778.73
|
| Rate for Payer: Cigna Commercial |
$1,103.20
|
| Rate for Payer: First Health Commercial |
$1,168.09
|
| Rate for Payer: First Health Workers Compensation |
$501.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,168.09
|
| Rate for Payer: GEHA Commercial |
$908.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,168.09
|
| Rate for Payer: Multiplan All |
$1,181.07
|
| Rate for Payer: OMNI Networks Commercial |
$908.52
|
| Rate for Payer: One Health Plan PPO/POS |
$1,168.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,232.99
|
| Rate for Payer: Three Rivers Provider Network All |
$973.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,207.03
|
| Rate for Payer: Zelis Auto |
$519.15
|
| Rate for Payer: Zelis Worker's Compensation |
$354.32
|
|
|
STAPLE RELOAD GREEN GST60G
|
Facility
|
OP
|
$1,297.88
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7007064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$324.47 |
| Max. Negotiated Rate |
$1,232.99 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$778.73
|
| Rate for Payer: Cash Price |
$778.73
|
| Rate for Payer: Cigna Commercial |
$1,103.20
|
| Rate for Payer: First Health Commercial |
$1,168.09
|
| Rate for Payer: First Health Workers Compensation |
$501.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,168.09
|
| Rate for Payer: GEHA Commercial |
$1,038.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,168.09
|
| Rate for Payer: Humana ChoiceCare |
$337.45
|
| Rate for Payer: Multiplan All |
$1,181.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$778.73
|
| Rate for Payer: OMNI Networks Commercial |
$908.52
|
| Rate for Payer: One Health Plan PPO/POS |
$1,168.09
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,232.99
|
| Rate for Payer: Three Rivers Provider Network All |
$973.41
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,142.13
|
| Rate for Payer: United Healthcare Managed Medicaid |
$324.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,207.03
|
| Rate for Payer: Zelis Auto |
$519.15
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$648.94
|
| Rate for Payer: Zelis Worker's Compensation |
$354.32
|
|
|
STAPLE RELOAD WHITE THIN TR45W
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007059
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$199.29 |
| Max. Negotiated Rate |
$693.50 |
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cigna Commercial |
$620.50
|
| Rate for Payer: First Health Commercial |
$657.00
|
| Rate for Payer: First Health Workers Compensation |
$281.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$657.00
|
| Rate for Payer: GEHA Commercial |
$511.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$657.00
|
| Rate for Payer: Multiplan All |
$664.30
|
| Rate for Payer: OMNI Networks Commercial |
$511.00
|
| Rate for Payer: One Health Plan PPO/POS |
$657.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$693.50
|
| Rate for Payer: Three Rivers Provider Network All |
$547.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$678.90
|
| Rate for Payer: Zelis Auto |
$292.00
|
| Rate for Payer: Zelis Worker's Compensation |
$199.29
|
|
|
STAPLE RELOAD WHITE THIN TR45W
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007059
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$182.50 |
| Max. Negotiated Rate |
$693.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$438.00
|
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cigna Commercial |
$620.50
|
| Rate for Payer: First Health Commercial |
$657.00
|
| Rate for Payer: First Health Workers Compensation |
$281.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$657.00
|
| Rate for Payer: GEHA Commercial |
$584.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$657.00
|
| Rate for Payer: Humana ChoiceCare |
$189.80
|
| Rate for Payer: Multiplan All |
$664.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$438.00
|
| Rate for Payer: OMNI Networks Commercial |
$511.00
|
| Rate for Payer: One Health Plan PPO/POS |
$657.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$693.50
|
| Rate for Payer: Three Rivers Provider Network All |
$547.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$642.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$182.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$678.90
|
| Rate for Payer: Zelis Auto |
$292.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$365.00
|
| Rate for Payer: Zelis Worker's Compensation |
$199.29
|
|
|
STAPLER LINEAR PROXIMATE 60MM
|
Facility
|
OP
|
$573.68
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$143.42 |
| Max. Negotiated Rate |
$545.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$344.21
|
| Rate for Payer: Cash Price |
$344.21
|
| Rate for Payer: Cash Price |
$344.21
|
| Rate for Payer: Cigna Commercial |
$487.63
|
| Rate for Payer: First Health Commercial |
$516.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$516.31
|
| Rate for Payer: GEHA Commercial |
$458.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$516.31
|
| Rate for Payer: Humana ChoiceCare |
$149.16
|
| Rate for Payer: Multiplan All |
$522.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$344.21
|
| Rate for Payer: OMNI Networks Commercial |
$401.58
|
| Rate for Payer: One Health Plan PPO/POS |
$516.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$545.00
|
| Rate for Payer: Three Rivers Provider Network All |
$430.26
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$504.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$143.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$533.52
|
| Rate for Payer: Zelis Auto |
$229.47
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$286.84
|
|
|
STAPLER LINEAR PROXIMATE 60MM
|
Facility
|
IP
|
$573.68
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.47 |
| Max. Negotiated Rate |
$545.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$458.94
|
| Rate for Payer: Cash Price |
$344.21
|
| Rate for Payer: Cash Price |
$344.21
|
| Rate for Payer: Cigna Commercial |
$487.63
|
| Rate for Payer: First Health Commercial |
$516.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$516.31
|
| Rate for Payer: GEHA Commercial |
$401.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$516.31
|
| Rate for Payer: Multiplan All |
$522.05
|
| Rate for Payer: OMNI Networks Commercial |
$401.58
|
| Rate for Payer: One Health Plan PPO/POS |
$516.31
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$545.00
|
| Rate for Payer: Three Rivers Provider Network All |
$430.26
|
| Rate for Payer: United Payors & United Providers UP&UP |
$533.52
|
| Rate for Payer: Zelis Auto |
$229.47
|
|
|
ST ASSISTIVE TECH EVAL
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 97755
|
| Hospital Charge Code |
5903044
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$39.52 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$51.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$51.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$40.65
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$39.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$41.48
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$91.20
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$47.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$41.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$133.76
|
| Rate for Payer: United Healthcare Commercial |
$129.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$76.00
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
ST ASSISTIVE TECH EVAL
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 97755
|
| Hospital Charge Code |
5903044
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
ST BEH & QUAL VC REASON
|
Facility
|
IP
|
$462.00
|
|
|
Service Code
|
CPT 92524
|
| Hospital Charge Code |
5903213
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$126.13 |
| Max. Negotiated Rate |
$438.90 |
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cigna Commercial |
$392.70
|
| Rate for Payer: First Health Commercial |
$415.80
|
| Rate for Payer: First Health Workers Compensation |
$178.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$415.80
|
| Rate for Payer: GEHA Commercial |
$323.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$415.80
|
| Rate for Payer: Multiplan All |
$420.42
|
| Rate for Payer: OMNI Networks Commercial |
$323.40
|
| Rate for Payer: One Health Plan PPO/POS |
$415.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$438.90
|
| Rate for Payer: Three Rivers Provider Network All |
$346.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$429.66
|
| Rate for Payer: Zelis Auto |
$184.80
|
| Rate for Payer: Zelis Worker's Compensation |
$126.13
|
|
|
ST BEH & QUAL VC REASON
|
Facility
|
OP
|
$462.00
|
|
|
Service Code
|
CPT 92524
|
| Hospital Charge Code |
5903213
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$438.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$176.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$277.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$176.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$140.10
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cigna Commercial |
$392.70
|
| Rate for Payer: First Health Commercial |
$415.80
|
| Rate for Payer: First Health Workers Compensation |
$178.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$415.80
|
| Rate for Payer: GEHA Commercial |
$369.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$415.80
|
| Rate for Payer: Humana ChoiceCare |
$120.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$142.95
|
| Rate for Payer: Multiplan All |
$420.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$277.20
|
| Rate for Payer: OMNI Networks Commercial |
$323.40
|
| Rate for Payer: One Health Plan PPO/POS |
$415.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$165.06
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$142.95
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$438.90
|
| Rate for Payer: Three Rivers Provider Network All |
$346.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$406.56
|
| Rate for Payer: United Healthcare Commercial |
$392.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$429.66
|
| Rate for Payer: Zelis Auto |
$184.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.00
|
| Rate for Payer: Zelis Worker's Compensation |
$126.13
|
|
|
ST COGNITIVE SKILLS DEVELOPMENT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT G0515
|
| Hospital Charge Code |
5900047
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Commercial |
$73.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
ST COGNITIVE SKILLS DEVELOPMENT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT G0515
|
| Hospital Charge Code |
5900047
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
ST DEVELOPMENTAL SCREENING
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 96110
|
| Hospital Charge Code |
5996110
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$18.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$18.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$14.32
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$304.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Humana ChoiceCare |
$98.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14.61
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$228.00
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$334.40
|
| Rate for Payer: United Healthcare Commercial |
$323.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
ST DEVELOPMENTAL SCREENING
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 96110
|
| Hospital Charge Code |
5996110
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$266.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
ST ENDOSCOPY SWALLOW TST (FEES)
|
Facility
|
OP
|
$796.00
|
|
|
Service Code
|
CPT 92612
|
| Hospital Charge Code |
5992612
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$101.53 |
| Max. Negotiated Rate |
$756.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$128.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$477.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$128.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$101.53
|
| Rate for Payer: Cash Price |
$477.60
|
| Rate for Payer: Cash Price |
$477.60
|
| Rate for Payer: Cigna Commercial |
$676.60
|
| Rate for Payer: First Health Commercial |
$716.40
|
| Rate for Payer: First Health Workers Compensation |
$307.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$716.40
|
| Rate for Payer: GEHA Commercial |
$636.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$716.40
|
| Rate for Payer: Humana ChoiceCare |
$206.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$103.60
|
| Rate for Payer: Multiplan All |
$724.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$477.60
|
| Rate for Payer: OMNI Networks Commercial |
$557.20
|
| Rate for Payer: One Health Plan PPO/POS |
$716.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$119.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$103.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$756.20
|
| Rate for Payer: Three Rivers Provider Network All |
$597.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$700.48
|
| Rate for Payer: United Healthcare Commercial |
$676.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$103.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$740.28
|
| Rate for Payer: Zelis Auto |
$318.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$398.00
|
| Rate for Payer: Zelis Worker's Compensation |
$217.31
|
|
|
ST ENDOSCOPY SWALLOW TST (FEES)
|
Facility
|
IP
|
$796.00
|
|
|
Service Code
|
CPT 92612
|
| Hospital Charge Code |
5992612
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$217.31 |
| Max. Negotiated Rate |
$756.20 |
| Rate for Payer: Cash Price |
$477.60
|
| Rate for Payer: Cigna Commercial |
$676.60
|
| Rate for Payer: First Health Commercial |
$716.40
|
| Rate for Payer: First Health Workers Compensation |
$307.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$716.40
|
| Rate for Payer: GEHA Commercial |
$557.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$716.40
|
| Rate for Payer: Multiplan All |
$724.36
|
| Rate for Payer: OMNI Networks Commercial |
$557.20
|
| Rate for Payer: One Health Plan PPO/POS |
$716.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$756.20
|
| Rate for Payer: Three Rivers Provider Network All |
$597.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$740.28
|
| Rate for Payer: Zelis Auto |
$318.40
|
| Rate for Payer: Zelis Worker's Compensation |
$217.31
|
|
|
ST ENDOSCOPY SWALLOW TST, INTERP & RPT
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 92613
|
| Hospital Charge Code |
5992613
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$168.30
|
| Rate for Payer: First Health Commercial |
$178.20
|
| Rate for Payer: First Health Workers Compensation |
$76.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$178.20
|
| Rate for Payer: GEHA Commercial |
$138.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$178.20
|
| Rate for Payer: Multiplan All |
$180.18
|
| Rate for Payer: OMNI Networks Commercial |
$138.60
|
| Rate for Payer: One Health Plan PPO/POS |
$178.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$188.10
|
| Rate for Payer: Three Rivers Provider Network All |
$148.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$184.14
|
| Rate for Payer: Zelis Auto |
$79.20
|
| Rate for Payer: Zelis Worker's Compensation |
$54.05
|
|
|
ST ENDOSCOPY SWALLOW TST, INTERP & RPT
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 92613
|
| Hospital Charge Code |
5992613
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$168.30
|
| Rate for Payer: First Health Commercial |
$178.20
|
| Rate for Payer: First Health Workers Compensation |
$76.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$178.20
|
| Rate for Payer: GEHA Commercial |
$158.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$178.20
|
| Rate for Payer: Humana ChoiceCare |
$51.48
|
| Rate for Payer: Multiplan All |
$180.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$118.80
|
| Rate for Payer: OMNI Networks Commercial |
$138.60
|
| Rate for Payer: One Health Plan PPO/POS |
$178.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$188.10
|
| Rate for Payer: Three Rivers Provider Network All |
$148.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$174.24
|
| Rate for Payer: United Healthcare Commercial |
$168.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$184.14
|
| Rate for Payer: Zelis Auto |
$79.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.00
|
| Rate for Payer: Zelis Worker's Compensation |
$54.05
|
|
|
STENT PLMT CTR DIALYSIS SEG
|
Facility
|
IP
|
$669.00
|
|
|
Service Code
|
CPT 36908
|
| Hospital Charge Code |
6191056
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$182.64 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: First Health Workers Compensation |
$258.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$468.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
| Rate for Payer: Zelis Worker's Compensation |
$182.64
|
|
|
STENT PLMT CTR DIALYSIS SEG
|
Facility
|
OP
|
$669.00
|
|
|
Service Code
|
CPT 36908
|
| Hospital Charge Code |
6191056
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$167.25 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: First Health Workers Compensation |
$258.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$535.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Humana ChoiceCare |
$173.94
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$401.40
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$588.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$167.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$334.50
|
| Rate for Payer: Zelis Worker's Compensation |
$182.64
|
|
