|
STERILE WATER FOR INJ 10ML
|
Facility
|
OP
|
$7.52
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3300949
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$7.14 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.09
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$6.39
|
| Rate for Payer: First Health Commercial |
$6.77
|
| Rate for Payer: First Health Workers Compensation |
$2.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.77
|
| Rate for Payer: GEHA Commercial |
$6.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.77
|
| Rate for Payer: Humana ChoiceCare |
$1.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.12
|
| Rate for Payer: Multiplan All |
$6.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.51
|
| Rate for Payer: OMNI Networks Commercial |
$5.26
|
| Rate for Payer: One Health Plan PPO/POS |
$6.77
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.14
|
| Rate for Payer: Three Rivers Provider Network All |
$5.64
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.99
|
| Rate for Payer: Zelis Auto |
$3.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.76
|
| Rate for Payer: Zelis Worker's Compensation |
$2.05
|
|
|
STERILE WATER FOR INJ 10ML
|
Facility
|
IP
|
$7.52
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3300949
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$7.14 |
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$6.39
|
| Rate for Payer: First Health Commercial |
$6.77
|
| Rate for Payer: First Health Workers Compensation |
$2.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.77
|
| Rate for Payer: GEHA Commercial |
$5.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.77
|
| Rate for Payer: Multiplan All |
$6.84
|
| Rate for Payer: OMNI Networks Commercial |
$5.26
|
| Rate for Payer: One Health Plan PPO/POS |
$6.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.14
|
| Rate for Payer: Three Rivers Provider Network All |
$5.64
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.99
|
| Rate for Payer: Zelis Auto |
$3.01
|
| Rate for Payer: Zelis Worker's Compensation |
$2.05
|
|
|
STERILE WATER FOR INJ 20ML
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3302950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
STERILE WATER FOR INJ 20ML
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3302950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.09
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.12
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
STERILE WATER FOR INJ 50ML
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3302968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1.09
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
STERILE WATER FOR INJ 50ML
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
3302968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
STERITALC 3G/VIAL
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
3302819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$214.85 |
| Max. Negotiated Rate |
$747.65 |
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$668.95
|
| Rate for Payer: First Health Commercial |
$708.30
|
| Rate for Payer: First Health Workers Compensation |
$303.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$708.30
|
| Rate for Payer: GEHA Commercial |
$550.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$708.30
|
| Rate for Payer: Multiplan All |
$716.17
|
| Rate for Payer: OMNI Networks Commercial |
$550.90
|
| Rate for Payer: One Health Plan PPO/POS |
$708.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$747.65
|
| Rate for Payer: Three Rivers Provider Network All |
$590.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$731.91
|
| Rate for Payer: Zelis Auto |
$314.80
|
| Rate for Payer: Zelis Worker's Compensation |
$214.85
|
|
|
STERITALC 3G/VIAL
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
3302819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.75 |
| Max. Negotiated Rate |
$747.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$668.95
|
| Rate for Payer: First Health Commercial |
$708.30
|
| Rate for Payer: First Health Workers Compensation |
$303.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$708.30
|
| Rate for Payer: GEHA Commercial |
$629.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$708.30
|
| Rate for Payer: Humana ChoiceCare |
$204.62
|
| Rate for Payer: Multiplan All |
$716.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$472.20
|
| Rate for Payer: OMNI Networks Commercial |
$550.90
|
| Rate for Payer: One Health Plan PPO/POS |
$708.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$747.65
|
| Rate for Payer: Three Rivers Provider Network All |
$590.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$692.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$196.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$731.91
|
| Rate for Payer: Zelis Auto |
$314.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$393.50
|
| Rate for Payer: Zelis Worker's Compensation |
$214.85
|
|
|
STER LOC GUI BRST BX
|
Facility
|
IP
|
$895.00
|
|
| Hospital Charge Code |
2766909
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$244.34 |
| Max. Negotiated Rate |
$850.25 |
| Rate for Payer: Cash Price |
$537.00
|
| Rate for Payer: Cigna Commercial |
$760.75
|
| Rate for Payer: First Health Commercial |
$805.50
|
| Rate for Payer: First Health Workers Compensation |
$345.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$805.50
|
| Rate for Payer: GEHA Commercial |
$626.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$805.50
|
| Rate for Payer: Multiplan All |
$814.45
|
| Rate for Payer: OMNI Networks Commercial |
$626.50
|
| Rate for Payer: One Health Plan PPO/POS |
$805.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$850.25
|
| Rate for Payer: Three Rivers Provider Network All |
$671.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$832.35
|
| Rate for Payer: Zelis Auto |
$358.00
|
| Rate for Payer: Zelis Worker's Compensation |
$244.34
|
|
|
STER LOC GUI BRST BX
|
Facility
|
OP
|
$895.00
|
|
| Hospital Charge Code |
2766909
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$223.75 |
| Max. Negotiated Rate |
$850.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$537.00
|
| Rate for Payer: Cash Price |
$537.00
|
| Rate for Payer: Cigna Commercial |
$760.75
|
| Rate for Payer: First Health Commercial |
$805.50
|
| Rate for Payer: First Health Workers Compensation |
$345.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$805.50
|
| Rate for Payer: GEHA Commercial |
$716.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$805.50
|
| Rate for Payer: Humana ChoiceCare |
$232.70
|
| Rate for Payer: Multiplan All |
$814.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$537.00
|
| Rate for Payer: OMNI Networks Commercial |
$626.50
|
| Rate for Payer: One Health Plan PPO/POS |
$805.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$850.25
|
| Rate for Payer: Three Rivers Provider Network All |
$671.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$787.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$223.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$832.35
|
| Rate for Payer: Zelis Auto |
$358.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$447.50
|
| Rate for Payer: Zelis Worker's Compensation |
$244.34
|
|
|
STERNAL DEBRIDEMENT
|
Facility
|
OP
|
$1,113.00
|
|
|
Service Code
|
CPT 21627
|
| Hospital Charge Code |
6121627
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$278.25 |
| Max. Negotiated Rate |
$1,057.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$667.80
|
| Rate for Payer: Cash Price |
$667.80
|
| Rate for Payer: Cigna Commercial |
$946.05
|
| Rate for Payer: First Health Commercial |
$1,001.70
|
| Rate for Payer: First Health Workers Compensation |
$429.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,001.70
|
| Rate for Payer: GEHA Commercial |
$890.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,001.70
|
| Rate for Payer: Humana ChoiceCare |
$289.38
|
| Rate for Payer: Multiplan All |
$1,012.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$667.80
|
| Rate for Payer: OMNI Networks Commercial |
$779.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,001.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,057.35
|
| Rate for Payer: Three Rivers Provider Network All |
$834.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$979.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$278.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,035.09
|
| Rate for Payer: Zelis Auto |
$445.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$556.50
|
| Rate for Payer: Zelis Worker's Compensation |
$303.85
|
|
|
STERNAL DEBRIDEMENT
|
Facility
|
IP
|
$1,113.00
|
|
|
Service Code
|
CPT 21627
|
| Hospital Charge Code |
6121627
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$303.85 |
| Max. Negotiated Rate |
$1,057.35 |
| Rate for Payer: Cash Price |
$667.80
|
| Rate for Payer: Cigna Commercial |
$946.05
|
| Rate for Payer: First Health Commercial |
$1,001.70
|
| Rate for Payer: First Health Workers Compensation |
$429.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,001.70
|
| Rate for Payer: GEHA Commercial |
$779.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,001.70
|
| Rate for Payer: Multiplan All |
$1,012.83
|
| Rate for Payer: OMNI Networks Commercial |
$779.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,001.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,057.35
|
| Rate for Payer: Three Rivers Provider Network All |
$834.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,035.09
|
| Rate for Payer: Zelis Auto |
$445.20
|
| Rate for Payer: Zelis Worker's Compensation |
$303.85
|
|
|
ST EVAL FOR PRESCRIPTION OF NON-SPEEC
|
Facility
|
OP
|
$571.00
|
|
|
Service Code
|
CPT 92605
|
| Hospital Charge Code |
5992605
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$37.65 |
| Max. Negotiated Rate |
$542.45 |
| 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 |
$342.60
|
| 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 |
$342.60
|
| Rate for Payer: Cash Price |
$342.60
|
| Rate for Payer: Cigna Commercial |
$485.35
|
| Rate for Payer: First Health Commercial |
$513.90
|
| Rate for Payer: First Health Workers Compensation |
$220.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$513.90
|
| Rate for Payer: GEHA Commercial |
$456.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$513.90
|
| Rate for Payer: Humana ChoiceCare |
$148.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$38.41
|
| Rate for Payer: Multiplan All |
$519.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$342.60
|
| Rate for Payer: OMNI Networks Commercial |
$399.70
|
| Rate for Payer: One Health Plan PPO/POS |
$513.90
|
| 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 |
$542.45
|
| Rate for Payer: Three Rivers Provider Network All |
$428.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$502.48
|
| Rate for Payer: United Healthcare Commercial |
$485.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$531.03
|
| Rate for Payer: Zelis Auto |
$228.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$285.50
|
| Rate for Payer: Zelis Worker's Compensation |
$155.88
|
|
|
ST EVAL FOR PRESCRIPTION OF NON-SPEEC
|
Facility
|
IP
|
$571.00
|
|
|
Service Code
|
CPT 92605
|
| Hospital Charge Code |
5992605
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$155.88 |
| Max. Negotiated Rate |
$542.45 |
| Rate for Payer: Cash Price |
$342.60
|
| Rate for Payer: Cigna Commercial |
$485.35
|
| Rate for Payer: First Health Commercial |
$513.90
|
| Rate for Payer: First Health Workers Compensation |
$220.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$513.90
|
| Rate for Payer: GEHA Commercial |
$399.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$513.90
|
| Rate for Payer: Multiplan All |
$519.61
|
| Rate for Payer: OMNI Networks Commercial |
$399.70
|
| Rate for Payer: One Health Plan PPO/POS |
$513.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$542.45
|
| Rate for Payer: Three Rivers Provider Network All |
$428.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$531.03
|
| Rate for Payer: Zelis Auto |
$228.40
|
| Rate for Payer: Zelis Worker's Compensation |
$155.88
|
|
|
ST EVAL SPEECH FLUENCY
|
Facility
|
OP
|
$437.00
|
|
|
Service Code
|
CPT 92521
|
| Hospital Charge Code |
5903210
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$113.62 |
| Max. Negotiated Rate |
$415.15 |
| 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 |
$262.20
|
| 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 |
$262.20
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: First Health Workers Compensation |
$168.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$393.30
|
| Rate for Payer: GEHA Commercial |
$349.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$393.30
|
| Rate for Payer: Humana ChoiceCare |
$113.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$142.95
|
| Rate for Payer: Multiplan All |
$397.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$262.20
|
| Rate for Payer: OMNI Networks Commercial |
$305.90
|
| Rate for Payer: One Health Plan PPO/POS |
$393.30
|
| 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 |
$415.15
|
| Rate for Payer: Three Rivers Provider Network All |
$327.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$384.56
|
| Rate for Payer: United Healthcare Commercial |
$371.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$406.41
|
| Rate for Payer: Zelis Auto |
$174.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$218.50
|
| Rate for Payer: Zelis Worker's Compensation |
$119.30
|
|
|
ST EVAL SPEECH FLUENCY
|
Facility
|
IP
|
$437.00
|
|
|
Service Code
|
CPT 92521
|
| Hospital Charge Code |
5903210
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$119.30 |
| Max. Negotiated Rate |
$415.15 |
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: First Health Commercial |
$393.30
|
| Rate for Payer: First Health Workers Compensation |
$168.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$393.30
|
| Rate for Payer: GEHA Commercial |
$305.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$393.30
|
| Rate for Payer: Multiplan All |
$397.67
|
| Rate for Payer: OMNI Networks Commercial |
$305.90
|
| Rate for Payer: One Health Plan PPO/POS |
$393.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$415.15
|
| Rate for Payer: Three Rivers Provider Network All |
$327.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$406.41
|
| Rate for Payer: Zelis Auto |
$174.80
|
| Rate for Payer: Zelis Worker's Compensation |
$119.30
|
|
|
ST EVALUATION FOR PRESCRIP OF NON-SPEEC
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 92618
|
| Hospital Charge Code |
5992618
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
ST EVALUATION FOR PRESCRIP OF NON-SPEEC
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 92618
|
| Hospital Charge Code |
5992618
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$18.82 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.82
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna Commercial |
$142.80
|
| Rate for Payer: First Health Commercial |
$151.20
|
| Rate for Payer: First Health Workers Compensation |
$64.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$151.20
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$151.20
|
| Rate for Payer: Humana ChoiceCare |
$43.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$19.21
|
| Rate for Payer: Multiplan All |
$152.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$100.80
|
| Rate for Payer: OMNI Networks Commercial |
$117.60
|
| Rate for Payer: One Health Plan PPO/POS |
$151.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$22.18
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$19.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$159.60
|
| Rate for Payer: Three Rivers Provider Network All |
$126.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$147.84
|
| Rate for Payer: United Healthcare Commercial |
$142.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$156.24
|
| Rate for Payer: Zelis Auto |
$67.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$84.00
|
| Rate for Payer: Zelis Worker's Compensation |
$45.86
|
|
|
ST EVAL WITH LANG COMP
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
CPT 92523
|
| Hospital Charge Code |
5903212
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$138.68 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$355.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
ST EVAL WITH LANG COMP
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
CPT 92523
|
| Hospital Charge Code |
5903212
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$482.60 |
| 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 |
$304.80
|
| 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 |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$431.80
|
| Rate for Payer: First Health Commercial |
$457.20
|
| Rate for Payer: First Health Workers Compensation |
$196.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$457.20
|
| Rate for Payer: GEHA Commercial |
$406.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$457.20
|
| Rate for Payer: Humana ChoiceCare |
$132.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$142.95
|
| Rate for Payer: Multiplan All |
$462.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$304.80
|
| Rate for Payer: OMNI Networks Commercial |
$355.60
|
| Rate for Payer: One Health Plan PPO/POS |
$457.20
|
| 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 |
$482.60
|
| Rate for Payer: Three Rivers Provider Network All |
$381.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$447.04
|
| Rate for Payer: United Healthcare Commercial |
$431.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$142.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$472.44
|
| Rate for Payer: Zelis Auto |
$203.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$254.00
|
| Rate for Payer: Zelis Worker's Compensation |
$138.68
|
|
|
ST EX FOR SPEECH DEVICE RX 1HR
|
Facility
|
OP
|
$689.00
|
|
|
Service Code
|
CPT 92607
|
| Hospital Charge Code |
5992607
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$37.65 |
| Max. Negotiated Rate |
$654.55 |
| 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 |
$413.40
|
| 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 |
$413.40
|
| Rate for Payer: Cash Price |
$413.40
|
| Rate for Payer: Cigna Commercial |
$585.65
|
| Rate for Payer: First Health Commercial |
$620.10
|
| Rate for Payer: First Health Workers Compensation |
$266.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$620.10
|
| Rate for Payer: GEHA Commercial |
$551.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$620.10
|
| Rate for Payer: Humana ChoiceCare |
$179.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$38.41
|
| Rate for Payer: Multiplan All |
$626.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$413.40
|
| Rate for Payer: OMNI Networks Commercial |
$482.30
|
| Rate for Payer: One Health Plan PPO/POS |
$620.10
|
| 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 |
$654.55
|
| Rate for Payer: Three Rivers Provider Network All |
$516.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$606.32
|
| Rate for Payer: United Healthcare Commercial |
$585.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$640.77
|
| Rate for Payer: Zelis Auto |
$275.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$344.50
|
| Rate for Payer: Zelis Worker's Compensation |
$188.10
|
|
|
ST EX FOR SPEECH DEVICE RX 1HR
|
Facility
|
IP
|
$689.00
|
|
|
Service Code
|
CPT 92607
|
| Hospital Charge Code |
5992607
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$654.55 |
| Rate for Payer: Cash Price |
$413.40
|
| Rate for Payer: Cigna Commercial |
$585.65
|
| Rate for Payer: First Health Commercial |
$620.10
|
| Rate for Payer: First Health Workers Compensation |
$266.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$620.10
|
| Rate for Payer: GEHA Commercial |
$482.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$620.10
|
| Rate for Payer: Multiplan All |
$626.99
|
| Rate for Payer: OMNI Networks Commercial |
$482.30
|
| Rate for Payer: One Health Plan PPO/POS |
$620.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$654.55
|
| Rate for Payer: Three Rivers Provider Network All |
$516.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$640.77
|
| Rate for Payer: Zelis Auto |
$275.60
|
| Rate for Payer: Zelis Worker's Compensation |
$188.10
|
|
|
ST EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
CPT 92608
|
| Hospital Charge Code |
5992608
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$37.65 |
| Max. Negotiated Rate |
$287.85 |
| 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 |
$181.80
|
| 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 |
$181.80
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna Commercial |
$257.55
|
| Rate for Payer: First Health Commercial |
$272.70
|
| Rate for Payer: First Health Workers Compensation |
$116.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$272.70
|
| Rate for Payer: GEHA Commercial |
$242.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$272.70
|
| Rate for Payer: Humana ChoiceCare |
$78.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$38.41
|
| Rate for Payer: Multiplan All |
$275.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$181.80
|
| Rate for Payer: OMNI Networks Commercial |
$212.10
|
| Rate for Payer: One Health Plan PPO/POS |
$272.70
|
| 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 |
$287.85
|
| Rate for Payer: Three Rivers Provider Network All |
$227.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$266.64
|
| Rate for Payer: United Healthcare Commercial |
$257.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.41
|
| Rate for Payer: United Payors & United Providers UP&UP |
$281.79
|
| Rate for Payer: Zelis Auto |
$121.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$151.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.72
|
|
|
ST EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
CPT 92608
|
| Hospital Charge Code |
5992608
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$287.85 |
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna Commercial |
$257.55
|
| Rate for Payer: First Health Commercial |
$272.70
|
| Rate for Payer: First Health Workers Compensation |
$116.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$272.70
|
| Rate for Payer: GEHA Commercial |
$212.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$272.70
|
| Rate for Payer: Multiplan All |
$275.73
|
| Rate for Payer: OMNI Networks Commercial |
$212.10
|
| Rate for Payer: One Health Plan PPO/POS |
$272.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$287.85
|
| Rate for Payer: Three Rivers Provider Network All |
$227.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$281.79
|
| Rate for Payer: Zelis Auto |
$121.20
|
| Rate for Payer: Zelis Worker's Compensation |
$82.72
|
|
|
ST FEES W/LARYNGEAL SENSE TEST
|
Facility
|
OP
|
$852.00
|
|
|
Service Code
|
CPT 92616
|
| Hospital Charge Code |
5992616
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$101.53 |
| Max. Negotiated Rate |
$809.40 |
| 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 |
$511.20
|
| 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 |
$511.20
|
| Rate for Payer: Cash Price |
$511.20
|
| Rate for Payer: Cigna Commercial |
$724.20
|
| Rate for Payer: First Health Commercial |
$766.80
|
| Rate for Payer: First Health Workers Compensation |
$328.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$766.80
|
| Rate for Payer: GEHA Commercial |
$681.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$766.80
|
| Rate for Payer: Humana ChoiceCare |
$221.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$103.60
|
| Rate for Payer: Multiplan All |
$775.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$511.20
|
| Rate for Payer: OMNI Networks Commercial |
$596.40
|
| Rate for Payer: One Health Plan PPO/POS |
$766.80
|
| 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 |
$809.40
|
| Rate for Payer: Three Rivers Provider Network All |
$639.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$749.76
|
| Rate for Payer: United Healthcare Commercial |
$724.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$103.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$792.36
|
| Rate for Payer: Zelis Auto |
$340.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$426.00
|
| Rate for Payer: Zelis Worker's Compensation |
$232.60
|
|
