|
SUTURE LARGE INTESTINE
|
Facility
|
OP
|
$2,229.00
|
|
|
Service Code
|
CPT 44604
|
| Hospital Charge Code |
6144604
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$557.25 |
| Max. Negotiated Rate |
$2,117.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,337.40
|
| Rate for Payer: Cash Price |
$1,337.40
|
| Rate for Payer: Cigna Commercial |
$1,894.65
|
| Rate for Payer: First Health Commercial |
$2,006.10
|
| Rate for Payer: First Health Workers Compensation |
$860.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,006.10
|
| Rate for Payer: GEHA Commercial |
$1,783.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,006.10
|
| Rate for Payer: Humana ChoiceCare |
$579.54
|
| Rate for Payer: Multiplan All |
$2,028.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,337.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,560.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,006.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,117.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,671.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,961.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$557.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,072.97
|
| Rate for Payer: Zelis Auto |
$891.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,114.50
|
| Rate for Payer: Zelis Worker's Compensation |
$608.52
|
|
|
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY
|
Facility
|
OP
|
$13,566.52
|
|
|
Service Code
|
CPT 27385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,763.37 |
| Max. Negotiated Rate |
$13,566.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,783.26
|
| Rate for Payer: First Health Workers Compensation |
$8,730.06
|
| Rate for Payer: GEHA Medicare |
$6,783.26
|
| Rate for Payer: Humana ChoiceCare |
$7,461.59
|
| Rate for Payer: Humana Medicare Advantage |
$6,783.26
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$11,395.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,783.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11,531.54
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,783.26
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$13,566.52
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,647.59
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,783.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,783.26
|
| Rate for Payer: Zelis Medicare |
$5,765.77
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,139.91
|
| Rate for Payer: Zelis Worker's Compensation |
$6,172.77
|
|
|
SUTURE SMALL INTESTINE
|
Facility
|
OP
|
$2,985.00
|
|
|
Service Code
|
CPT 44602
|
| Hospital Charge Code |
6144602
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$746.25 |
| Max. Negotiated Rate |
$2,835.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,791.00
|
| Rate for Payer: Cash Price |
$1,791.00
|
| Rate for Payer: Cigna Commercial |
$2,537.25
|
| Rate for Payer: First Health Commercial |
$2,686.50
|
| Rate for Payer: First Health Workers Compensation |
$1,152.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,686.50
|
| Rate for Payer: GEHA Commercial |
$2,388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,686.50
|
| Rate for Payer: Humana ChoiceCare |
$776.10
|
| Rate for Payer: Multiplan All |
$2,716.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,791.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,089.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,686.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,835.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,238.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,626.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$746.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,776.05
|
| Rate for Payer: Zelis Auto |
$1,194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,492.50
|
| Rate for Payer: Zelis Worker's Compensation |
$814.90
|
|
|
SUTURE SMALL INTESTINE
|
Facility
|
IP
|
$2,985.00
|
|
|
Service Code
|
CPT 44602
|
| Hospital Charge Code |
6144602
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$814.90 |
| Max. Negotiated Rate |
$2,835.75 |
| Rate for Payer: Cash Price |
$1,791.00
|
| Rate for Payer: Cigna Commercial |
$2,537.25
|
| Rate for Payer: First Health Commercial |
$2,686.50
|
| Rate for Payer: First Health Workers Compensation |
$1,152.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,686.50
|
| Rate for Payer: GEHA Commercial |
$2,089.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,686.50
|
| Rate for Payer: Multiplan All |
$2,716.35
|
| Rate for Payer: OMNI Networks Commercial |
$2,089.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,686.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,835.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,238.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,776.05
|
| Rate for Payer: Zelis Auto |
$1,194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$814.90
|
|
|
SUTURE SMALL INTESTINE
|
Facility
|
IP
|
$3,419.00
|
|
|
Service Code
|
CPT 44603
|
| Hospital Charge Code |
6144603
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$933.39 |
| Max. Negotiated Rate |
$3,248.05 |
| Rate for Payer: Cash Price |
$2,051.40
|
| Rate for Payer: Cigna Commercial |
$2,906.15
|
| Rate for Payer: First Health Commercial |
$3,077.10
|
| Rate for Payer: First Health Workers Compensation |
$1,320.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,077.10
|
| Rate for Payer: GEHA Commercial |
$2,393.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,077.10
|
| Rate for Payer: Multiplan All |
$3,111.29
|
| Rate for Payer: OMNI Networks Commercial |
$2,393.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,077.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,248.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,564.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,179.67
|
| Rate for Payer: Zelis Auto |
$1,367.60
|
| Rate for Payer: Zelis Worker's Compensation |
$933.39
|
|
|
SUTURE SMALL INTESTINE
|
Facility
|
OP
|
$3,419.00
|
|
|
Service Code
|
CPT 44603
|
| Hospital Charge Code |
6144603
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$854.75 |
| Max. Negotiated Rate |
$3,248.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,051.40
|
| Rate for Payer: Cash Price |
$2,051.40
|
| Rate for Payer: Cigna Commercial |
$2,906.15
|
| Rate for Payer: First Health Commercial |
$3,077.10
|
| Rate for Payer: First Health Workers Compensation |
$1,320.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,077.10
|
| Rate for Payer: GEHA Commercial |
$2,735.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,077.10
|
| Rate for Payer: Humana ChoiceCare |
$888.94
|
| Rate for Payer: Multiplan All |
$3,111.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,051.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,393.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,077.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,248.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,564.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,008.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$854.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,179.67
|
| Rate for Payer: Zelis Auto |
$1,367.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,709.50
|
| Rate for Payer: Zelis Worker's Compensation |
$933.39
|
|
|
SUTURE,SURGICAL,STEEL,23GA.
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
90003938
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.75 |
| Max. Negotiated Rate |
$61.75 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$55.25
|
| Rate for Payer: First Health Commercial |
$58.50
|
| Rate for Payer: First Health Workers Compensation |
$25.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.50
|
| Rate for Payer: GEHA Commercial |
$45.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.50
|
| Rate for Payer: Multiplan All |
$59.15
|
| Rate for Payer: OMNI Networks Commercial |
$45.50
|
| Rate for Payer: One Health Plan PPO/POS |
$58.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$61.75
|
| Rate for Payer: Three Rivers Provider Network All |
$48.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.45
|
| Rate for Payer: Zelis Auto |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$17.75
|
|
|
SUTURE,SURGICAL,STEEL,23GA.
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
90003938
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$61.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$55.25
|
| Rate for Payer: First Health Commercial |
$58.50
|
| Rate for Payer: First Health Workers Compensation |
$25.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.50
|
| Rate for Payer: GEHA Commercial |
$52.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.50
|
| Rate for Payer: Humana ChoiceCare |
$16.90
|
| Rate for Payer: Multiplan All |
$59.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.00
|
| Rate for Payer: OMNI Networks Commercial |
$45.50
|
| Rate for Payer: One Health Plan PPO/POS |
$58.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$61.75
|
| Rate for Payer: Three Rivers Provider Network All |
$48.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$57.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.45
|
| Rate for Payer: Zelis Auto |
$26.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.50
|
| Rate for Payer: Zelis Worker's Compensation |
$17.75
|
|
|
SVC PRV EMER BASIS IN OFFICE DISRUPTING
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT 99058
|
| Hospital Charge Code |
9499058
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
SVC PRV EMER BASIS IN OFFICE DISRUPTING
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT 99058
|
| Hospital Charge Code |
9499058
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
SVN CONT 1ST HR
|
Facility
|
IP
|
$501.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
4009006
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$136.77 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$350.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
SVN CONT 1ST HR
|
Facility
|
OP
|
$501.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
4009006
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$104.04 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.40
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$400.80
|
| Rate for Payer: GEHA Medicare |
$122.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Humana ChoiceCare |
$134.64
|
| Rate for Payer: Humana Medicare Advantage |
$122.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.40
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.08
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.80
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.95
|
| Rate for Payer: United Healthcare Commercial |
$425.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.40
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Medicare |
$104.04
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.88
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
SVN CONT ADD HR
|
Facility
|
IP
|
$373.61
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
4009005
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$354.93 |
| Rate for Payer: Cash Price |
$224.17
|
| Rate for Payer: Cigna Commercial |
$317.57
|
| Rate for Payer: First Health Commercial |
$336.25
|
| Rate for Payer: First Health Workers Compensation |
$144.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$336.25
|
| Rate for Payer: GEHA Commercial |
$261.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$336.25
|
| Rate for Payer: Multiplan All |
$339.99
|
| Rate for Payer: OMNI Networks Commercial |
$261.53
|
| Rate for Payer: One Health Plan PPO/POS |
$336.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$354.93
|
| Rate for Payer: Three Rivers Provider Network All |
$280.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$347.46
|
| Rate for Payer: Zelis Auto |
$149.44
|
| Rate for Payer: Zelis Worker's Compensation |
$102.00
|
|
|
SVN CONT ADD HR
|
Facility
|
OP
|
$373.61
|
|
|
Service Code
|
CPT 94645
|
| Hospital Charge Code |
4009005
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$53.60 |
| Max. Negotiated Rate |
$354.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$67.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$224.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$67.67
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$53.60
|
| Rate for Payer: Cash Price |
$224.17
|
| Rate for Payer: Cash Price |
$224.17
|
| Rate for Payer: Cigna Commercial |
$317.57
|
| Rate for Payer: First Health Commercial |
$336.25
|
| Rate for Payer: First Health Workers Compensation |
$144.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$336.25
|
| Rate for Payer: GEHA Commercial |
$298.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$336.25
|
| Rate for Payer: Humana ChoiceCare |
$97.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$54.70
|
| Rate for Payer: Multiplan All |
$339.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$224.17
|
| Rate for Payer: OMNI Networks Commercial |
$261.53
|
| Rate for Payer: One Health Plan PPO/POS |
$336.25
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$63.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$54.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$354.93
|
| Rate for Payer: Three Rivers Provider Network All |
$280.21
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$328.78
|
| Rate for Payer: United Healthcare Commercial |
$317.57
|
| Rate for Payer: United Healthcare Managed Medicaid |
$54.70
|
| Rate for Payer: United Payors & United Providers UP&UP |
$347.46
|
| Rate for Payer: Zelis Auto |
$149.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$186.81
|
| Rate for Payer: Zelis Worker's Compensation |
$102.00
|
|
|
SVN FOURTH MED SUBSEQUENT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090010
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN FOURTH MED SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090010
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN INIT
|
Facility
|
IP
|
$473.42
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4000120
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$129.24 |
| Max. Negotiated Rate |
$449.75 |
| Rate for Payer: Cash Price |
$284.05
|
| Rate for Payer: Cigna Commercial |
$402.41
|
| Rate for Payer: First Health Commercial |
$426.08
|
| Rate for Payer: First Health Workers Compensation |
$182.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$426.08
|
| Rate for Payer: GEHA Commercial |
$331.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$426.08
|
| Rate for Payer: Multiplan All |
$430.81
|
| Rate for Payer: OMNI Networks Commercial |
$331.39
|
| Rate for Payer: One Health Plan PPO/POS |
$426.08
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.75
|
| Rate for Payer: Three Rivers Provider Network All |
$355.06
|
| Rate for Payer: United Payors & United Providers UP&UP |
$440.28
|
| Rate for Payer: Zelis Auto |
$189.37
|
| Rate for Payer: Zelis Worker's Compensation |
$129.24
|
|
|
SVN INIT
|
Facility
|
OP
|
$473.42
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4000120
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$129.24 |
| Max. Negotiated Rate |
$449.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$284.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$284.05
|
| Rate for Payer: Cash Price |
$284.05
|
| Rate for Payer: Cigna Commercial |
$402.41
|
| Rate for Payer: First Health Commercial |
$426.08
|
| Rate for Payer: First Health Workers Compensation |
$182.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$426.08
|
| Rate for Payer: GEHA Commercial |
$378.74
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$426.08
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$430.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$331.39
|
| Rate for Payer: One Health Plan PPO/POS |
$426.08
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$449.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$355.06
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$402.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$440.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$189.37
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$129.24
|
|
|
SVN SECOND MED SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090007
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN SECOND MED SUBSEQUENT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090007
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN THIRD MED SUBSEQUENT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090008
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN THIRD MED SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090008
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN TX SUB
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4020004
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SVN TX SUB
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4020004
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
SWING BED
|
Facility
|
IP
|
$1,250.00
|
|
| Hospital Charge Code |
31111005
|
|
Hospital Revenue Code
|
120
|
| Min. Negotiated Rate |
$341.25 |
| Max. Negotiated Rate |
$1,187.50 |
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,062.50
|
| Rate for Payer: First Health Commercial |
$1,125.00
|
| Rate for Payer: First Health Workers Compensation |
$482.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,125.00
|
| Rate for Payer: GEHA Commercial |
$875.00
|
| Rate for Payer: Gentiva Hospice Medicaid |
$977.29
|
| Rate for Payer: Gentiva Hospice Medicare |
$1,008.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,125.00
|
| Rate for Payer: Lakeview Christian Hospice Medicare |
$366.00
|
| Rate for Payer: Multiplan All |
$1,137.50
|
| Rate for Payer: OMNI Networks Commercial |
$875.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,125.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,187.50
|
| Rate for Payer: Three Rivers Provider Network All |
$937.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,162.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$360.00
|
| Rate for Payer: Zelis Auto |
$500.00
|
| Rate for Payer: Zelis Worker's Compensation |
$341.25
|
|
