|
SUB GRFT FSNHFGMD >/= 100SCM 1ST 100SQCM
|
Facility
|
IP
|
$727.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
6115277
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$198.47 |
| Max. Negotiated Rate |
$690.65 |
| Rate for Payer: Cash Price |
$436.20
|
| Rate for Payer: Cigna Commercial |
$617.95
|
| Rate for Payer: First Health Commercial |
$654.30
|
| Rate for Payer: First Health Workers Compensation |
$280.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$654.30
|
| Rate for Payer: GEHA Commercial |
$508.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$654.30
|
| Rate for Payer: Multiplan All |
$661.57
|
| Rate for Payer: OMNI Networks Commercial |
$508.90
|
| Rate for Payer: One Health Plan PPO/POS |
$654.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$690.65
|
| Rate for Payer: Three Rivers Provider Network All |
$545.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$676.11
|
| Rate for Payer: Zelis Auto |
$290.80
|
| Rate for Payer: Zelis Worker's Compensation |
$198.47
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM 1ST 100SQCM
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
6115277
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$198.47 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$502.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$436.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$502.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$397.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$436.20
|
| Rate for Payer: Cash Price |
$436.20
|
| Rate for Payer: Cigna Commercial |
$617.95
|
| Rate for Payer: First Health Commercial |
$654.30
|
| Rate for Payer: First Health Workers Compensation |
$280.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$654.30
|
| Rate for Payer: GEHA Commercial |
$581.60
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$654.30
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$405.79
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$661.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$508.90
|
| Rate for Payer: One Health Plan PPO/POS |
$654.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$468.54
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$405.79
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$690.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$545.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$405.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$676.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$290.80
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$198.47
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM 1ST 100SQCM
|
Facility
|
IP
|
$4,879.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
1905290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,331.97 |
| Max. Negotiated Rate |
$4,635.05 |
| Rate for Payer: Cash Price |
$2,927.40
|
| Rate for Payer: Cigna Commercial |
$4,147.15
|
| Rate for Payer: First Health Commercial |
$4,391.10
|
| Rate for Payer: First Health Workers Compensation |
$1,883.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,391.10
|
| Rate for Payer: GEHA Commercial |
$3,415.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,391.10
|
| Rate for Payer: Multiplan All |
$4,439.89
|
| Rate for Payer: OMNI Networks Commercial |
$3,415.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,391.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,635.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,659.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,537.47
|
| Rate for Payer: Zelis Auto |
$1,951.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,331.97
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM 1ST 100SQCM
|
Facility
|
IP
|
$1,024.00
|
|
|
Service Code
|
CPT 15277
|
| Hospital Charge Code |
20300125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$279.55 |
| Max. Negotiated Rate |
$972.80 |
| Rate for Payer: Cash Price |
$614.40
|
| Rate for Payer: Cigna Commercial |
$870.40
|
| Rate for Payer: First Health Commercial |
$921.60
|
| Rate for Payer: First Health Workers Compensation |
$395.37
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$921.60
|
| Rate for Payer: GEHA Commercial |
$716.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$921.60
|
| Rate for Payer: Multiplan All |
$931.84
|
| Rate for Payer: OMNI Networks Commercial |
$716.80
|
| Rate for Payer: One Health Plan PPO/POS |
$921.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$972.80
|
| Rate for Payer: Three Rivers Provider Network All |
$768.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$952.32
|
| Rate for Payer: Zelis Auto |
$409.60
|
| Rate for Payer: Zelis Worker's Compensation |
$279.55
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
IP
|
$3,868.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
1905291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,055.96 |
| Max. Negotiated Rate |
$3,674.60 |
| Rate for Payer: Cash Price |
$2,320.80
|
| Rate for Payer: Cigna Commercial |
$3,287.80
|
| Rate for Payer: First Health Commercial |
$3,481.20
|
| Rate for Payer: First Health Workers Compensation |
$1,493.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,481.20
|
| Rate for Payer: GEHA Commercial |
$2,707.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,481.20
|
| Rate for Payer: Multiplan All |
$3,519.88
|
| Rate for Payer: OMNI Networks Commercial |
$2,707.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,481.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,674.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,901.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,597.24
|
| Rate for Payer: Zelis Auto |
$1,547.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,055.96
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
IP
|
$273.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
20300126
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.53 |
| Max. Negotiated Rate |
$259.35 |
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$232.05
|
| Rate for Payer: First Health Commercial |
$245.70
|
| Rate for Payer: First Health Workers Compensation |
$105.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$245.70
|
| Rate for Payer: GEHA Commercial |
$191.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$245.70
|
| Rate for Payer: Multiplan All |
$248.43
|
| Rate for Payer: OMNI Networks Commercial |
$191.10
|
| Rate for Payer: One Health Plan PPO/POS |
$245.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$259.35
|
| Rate for Payer: Three Rivers Provider Network All |
$204.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$253.89
|
| Rate for Payer: Zelis Auto |
$109.20
|
| Rate for Payer: Zelis Worker's Compensation |
$74.53
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
OP
|
$273.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
20300126
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$328.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$163.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cigna Commercial |
$232.05
|
| Rate for Payer: First Health Commercial |
$245.70
|
| Rate for Payer: First Health Workers Compensation |
$105.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$245.70
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$245.70
|
| Rate for Payer: Humana ChoiceCare |
$70.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Multiplan All |
$248.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$163.80
|
| Rate for Payer: OMNI Networks Commercial |
$191.10
|
| Rate for Payer: One Health Plan PPO/POS |
$245.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$259.35
|
| Rate for Payer: Three Rivers Provider Network All |
$204.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$240.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$253.89
|
| Rate for Payer: Zelis Auto |
$109.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$136.50
|
| Rate for Payer: Zelis Worker's Compensation |
$74.53
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
6115278
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$50.23 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: First Health Commercial |
$165.60
|
| Rate for Payer: First Health Workers Compensation |
$71.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$165.60
|
| Rate for Payer: GEHA Commercial |
$128.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$165.60
|
| Rate for Payer: Multiplan All |
$167.44
|
| Rate for Payer: OMNI Networks Commercial |
$128.80
|
| Rate for Payer: One Health Plan PPO/POS |
$165.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$174.80
|
| Rate for Payer: Three Rivers Provider Network All |
$138.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$171.12
|
| Rate for Payer: Zelis Auto |
$73.60
|
| Rate for Payer: Zelis Worker's Compensation |
$50.23
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
6115278
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.84 |
| Max. Negotiated Rate |
$328.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$110.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: First Health Commercial |
$165.60
|
| Rate for Payer: First Health Workers Compensation |
$71.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$165.60
|
| Rate for Payer: GEHA Commercial |
$147.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$165.60
|
| Rate for Payer: Humana ChoiceCare |
$47.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Multiplan All |
$167.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$110.40
|
| Rate for Payer: OMNI Networks Commercial |
$128.80
|
| Rate for Payer: One Health Plan PPO/POS |
$165.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$174.80
|
| Rate for Payer: Three Rivers Provider Network All |
$138.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$161.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$171.12
|
| Rate for Payer: Zelis Auto |
$73.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$92.00
|
| Rate for Payer: Zelis Worker's Compensation |
$50.23
|
|
|
SUB GRFT FSNHFGMD >/= 100SCM ADL 100SQCM
|
Facility
|
OP
|
$3,868.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
1905291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.61 |
| Max. Negotiated Rate |
$3,674.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,320.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Cash Price |
$2,320.80
|
| Rate for Payer: Cash Price |
$2,320.80
|
| Rate for Payer: Cigna Commercial |
$3,287.80
|
| Rate for Payer: First Health Commercial |
$3,481.20
|
| Rate for Payer: First Health Workers Compensation |
$1,493.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,481.20
|
| Rate for Payer: GEHA Commercial |
$3,094.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,481.20
|
| Rate for Payer: Humana ChoiceCare |
$1,005.68
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Multiplan All |
$3,519.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,320.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,707.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,481.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,674.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,901.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,403.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,597.24
|
| Rate for Payer: Zelis Auto |
$1,547.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,934.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,055.96
|
|
|
SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 2
|
Facility
|
IP
|
$4,624.61
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9615275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,262.52 |
| Max. Negotiated Rate |
$4,393.38 |
| Rate for Payer: Cash Price |
$2,774.77
|
| Rate for Payer: Cigna Commercial |
$3,930.92
|
| Rate for Payer: First Health Commercial |
$4,162.15
|
| Rate for Payer: First Health Workers Compensation |
$1,785.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,162.15
|
| Rate for Payer: GEHA Commercial |
$3,237.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,162.15
|
| Rate for Payer: Multiplan All |
$4,208.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,237.23
|
| Rate for Payer: One Health Plan PPO/POS |
$4,162.15
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,393.38
|
| Rate for Payer: Three Rivers Provider Network All |
$3,468.46
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,300.89
|
| Rate for Payer: Zelis Auto |
$1,849.84
|
| Rate for Payer: Zelis Worker's Compensation |
$1,262.52
|
|
|
SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 2
|
Facility
|
OP
|
$4,624.61
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9615275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.61 |
| Max. Negotiated Rate |
$4,393.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,774.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$2,774.77
|
| Rate for Payer: Cash Price |
$2,774.77
|
| Rate for Payer: Cigna Commercial |
$3,930.92
|
| Rate for Payer: First Health Commercial |
$4,162.15
|
| Rate for Payer: First Health Workers Compensation |
$1,785.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,162.15
|
| Rate for Payer: GEHA Commercial |
$3,699.69
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,162.15
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$4,208.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$3,237.23
|
| Rate for Payer: One Health Plan PPO/POS |
$4,162.15
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,393.38
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$3,468.46
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,300.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$1,849.84
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$1,262.52
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
20300123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$126.67 |
| Max. Negotiated Rate |
$440.80 |
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cigna Commercial |
$394.40
|
| Rate for Payer: First Health Commercial |
$417.60
|
| Rate for Payer: First Health Workers Compensation |
$179.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$417.60
|
| Rate for Payer: GEHA Commercial |
$324.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$417.60
|
| Rate for Payer: Multiplan All |
$422.24
|
| Rate for Payer: OMNI Networks Commercial |
$324.80
|
| Rate for Payer: One Health Plan PPO/POS |
$417.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$440.80
|
| Rate for Payer: Three Rivers Provider Network All |
$348.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$431.52
|
| Rate for Payer: Zelis Auto |
$185.60
|
| Rate for Payer: Zelis Worker's Compensation |
$126.67
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
20300123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$126.67 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$278.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cigna Commercial |
$394.40
|
| Rate for Payer: First Health Commercial |
$417.60
|
| Rate for Payer: First Health Workers Compensation |
$179.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$417.60
|
| Rate for Payer: GEHA Commercial |
$371.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$417.60
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$422.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$324.80
|
| Rate for Payer: One Health Plan PPO/POS |
$417.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$440.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$348.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$431.52
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$185.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$126.67
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
IP
|
$299.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
6115275
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$284.05 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$115.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$209.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Worker's Compensation |
$81.63
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
OP
|
$4,694.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
1905288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.61 |
| Max. Negotiated Rate |
$4,459.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,816.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$2,816.40
|
| Rate for Payer: Cash Price |
$2,816.40
|
| Rate for Payer: Cigna Commercial |
$3,989.90
|
| Rate for Payer: First Health Commercial |
$4,224.60
|
| Rate for Payer: First Health Workers Compensation |
$1,812.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,224.60
|
| Rate for Payer: GEHA Commercial |
$3,755.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,224.60
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$4,271.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$3,285.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,224.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,459.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$3,520.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,365.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$1,877.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$1,281.46
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
OP
|
$299.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
6115275
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$179.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$328.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$260.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$115.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$239.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$265.91
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$307.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$265.91
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$265.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$81.63
|
|
|
SUB GRFT FSNHFGMD <100SQCM 1ST 25SQCM
|
Facility
|
IP
|
$4,694.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
1905288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,281.46 |
| Max. Negotiated Rate |
$4,459.30 |
| Rate for Payer: Cash Price |
$2,816.40
|
| Rate for Payer: Cigna Commercial |
$3,989.90
|
| Rate for Payer: First Health Commercial |
$4,224.60
|
| Rate for Payer: First Health Workers Compensation |
$1,812.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,224.60
|
| Rate for Payer: GEHA Commercial |
$3,285.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,224.60
|
| Rate for Payer: Multiplan All |
$4,271.54
|
| Rate for Payer: OMNI Networks Commercial |
$3,285.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,224.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,459.30
|
| Rate for Payer: Three Rivers Provider Network All |
$3,520.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,365.42
|
| Rate for Payer: Zelis Auto |
$1,877.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,281.46
|
|
|
SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADD
|
Facility
|
IP
|
$2,962.72
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
9615276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$808.82 |
| Max. Negotiated Rate |
$2,814.58 |
| Rate for Payer: Cash Price |
$1,777.63
|
| Rate for Payer: Cigna Commercial |
$2,518.31
|
| Rate for Payer: First Health Commercial |
$2,666.45
|
| Rate for Payer: First Health Workers Compensation |
$1,143.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,666.45
|
| Rate for Payer: GEHA Commercial |
$2,073.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,666.45
|
| Rate for Payer: Multiplan All |
$2,696.08
|
| Rate for Payer: OMNI Networks Commercial |
$2,073.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,666.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,814.58
|
| Rate for Payer: Three Rivers Provider Network All |
$2,222.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,755.33
|
| Rate for Payer: Zelis Auto |
$1,185.09
|
| Rate for Payer: Zelis Worker's Compensation |
$808.82
|
|
|
SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADD
|
Facility
|
OP
|
$2,962.72
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
9615276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.59 |
| Max. Negotiated Rate |
$2,814.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,777.63
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$1,777.63
|
| Rate for Payer: Cash Price |
$1,777.63
|
| Rate for Payer: Cigna Commercial |
$2,518.31
|
| Rate for Payer: First Health Commercial |
$2,666.45
|
| Rate for Payer: First Health Workers Compensation |
$1,143.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,666.45
|
| Rate for Payer: GEHA Commercial |
$2,370.18
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,666.45
|
| Rate for Payer: Humana ChoiceCare |
$770.31
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$2,696.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,777.63
|
| Rate for Payer: OMNI Networks Commercial |
$2,073.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,666.45
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,814.58
|
| Rate for Payer: Three Rivers Provider Network All |
$2,222.04
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,607.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,755.33
|
| Rate for Payer: Zelis Auto |
$1,185.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,481.36
|
| Rate for Payer: Zelis Worker's Compensation |
$808.82
|
|
|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
IP
|
$3,007.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
1905289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$820.91 |
| Max. Negotiated Rate |
$2,856.65 |
| Rate for Payer: Cash Price |
$1,804.20
|
| Rate for Payer: Cigna Commercial |
$2,555.95
|
| Rate for Payer: First Health Commercial |
$2,706.30
|
| Rate for Payer: First Health Workers Compensation |
$1,161.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,706.30
|
| Rate for Payer: GEHA Commercial |
$2,104.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,706.30
|
| Rate for Payer: Multiplan All |
$2,736.37
|
| Rate for Payer: OMNI Networks Commercial |
$2,104.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,706.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,856.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,255.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,796.51
|
| Rate for Payer: Zelis Auto |
$1,202.80
|
| Rate for Payer: Zelis Worker's Compensation |
$820.91
|
|
|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
6115276
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
OP
|
$3,007.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
1905289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.59 |
| Max. Negotiated Rate |
$2,856.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,804.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$1,804.20
|
| Rate for Payer: Cash Price |
$1,804.20
|
| Rate for Payer: Cigna Commercial |
$2,555.95
|
| Rate for Payer: First Health Commercial |
$2,706.30
|
| Rate for Payer: First Health Workers Compensation |
$1,161.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,706.30
|
| Rate for Payer: GEHA Commercial |
$2,405.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,706.30
|
| Rate for Payer: Humana ChoiceCare |
$781.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$2,736.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,804.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,104.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,706.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,856.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,255.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,646.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,796.51
|
| Rate for Payer: Zelis Auto |
$1,202.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,503.50
|
| Rate for Payer: Zelis Worker's Compensation |
$820.91
|
|
|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
20300124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
20300124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.56 |
| Max. Negotiated Rate |
$120.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$120.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$95.59
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$97.53
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$112.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$97.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$97.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
