|
US (PROSTRATE) TRANSRECTAL
|
Facility
|
OP
|
$652.00
|
|
|
Service Code
|
CPT 76872
|
| Hospital Charge Code |
9200017
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$619.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$391.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$554.20
|
| Rate for Payer: First Health Commercial |
$586.80
|
| Rate for Payer: First Health Workers Compensation |
$241.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$586.80
|
| Rate for Payer: GEHA Commercial |
$521.60
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$586.80
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$593.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$456.40
|
| Rate for Payer: One Health Plan PPO/POS |
$586.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$619.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$489.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$606.36
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$260.80
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$170.55
|
|
|
US (PROSTRATE) TRANSRECTAL
|
Facility
|
IP
|
$652.00
|
|
|
Service Code
|
CPT 76872
|
| Hospital Charge Code |
9200017
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$170.55 |
| Max. Negotiated Rate |
$619.40 |
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$554.20
|
| Rate for Payer: First Health Commercial |
$586.80
|
| Rate for Payer: First Health Workers Compensation |
$241.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$586.80
|
| Rate for Payer: GEHA Commercial |
$456.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$586.80
|
| Rate for Payer: Multiplan All |
$593.32
|
| Rate for Payer: OMNI Networks Commercial |
$456.40
|
| Rate for Payer: One Health Plan PPO/POS |
$586.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$619.40
|
| Rate for Payer: Three Rivers Provider Network All |
$489.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$606.36
|
| Rate for Payer: Zelis Auto |
$260.80
|
| Rate for Payer: Zelis Worker's Compensation |
$170.55
|
|
|
US RENAL
|
Facility
|
IP
|
$1,013.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
2476775
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$962.35 |
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cigna Commercial |
$861.05
|
| Rate for Payer: First Health Commercial |
$911.70
|
| Rate for Payer: First Health Workers Compensation |
$104.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$911.70
|
| Rate for Payer: GEHA Commercial |
$709.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$911.70
|
| Rate for Payer: Multiplan All |
$921.83
|
| Rate for Payer: OMNI Networks Commercial |
$709.10
|
| Rate for Payer: One Health Plan PPO/POS |
$911.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$962.35
|
| Rate for Payer: Three Rivers Provider Network All |
$759.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$942.09
|
| Rate for Payer: Zelis Auto |
$405.20
|
| Rate for Payer: Zelis Worker's Compensation |
$73.82
|
|
|
US RENAL
|
Facility
|
OP
|
$1,013.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
2476775
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$962.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$607.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cigna Commercial |
$861.05
|
| Rate for Payer: First Health Commercial |
$911.70
|
| Rate for Payer: First Health Workers Compensation |
$104.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$911.70
|
| Rate for Payer: GEHA Commercial |
$810.40
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$911.70
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$921.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$709.10
|
| Rate for Payer: One Health Plan PPO/POS |
$911.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$962.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$759.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$861.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$942.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$405.20
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$73.82
|
|
|
US REPAIR PSUEDO AN
|
Facility
|
IP
|
$1,945.00
|
|
|
Service Code
|
CPT 76936
|
| Hospital Charge Code |
2600543
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$226.84 |
| Max. Negotiated Rate |
$1,847.75 |
| Rate for Payer: Cash Price |
$1,167.00
|
| Rate for Payer: Cash Price |
$1,167.00
|
| Rate for Payer: Cigna Commercial |
$1,653.25
|
| Rate for Payer: First Health Commercial |
$1,750.50
|
| Rate for Payer: First Health Workers Compensation |
$320.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,750.50
|
| Rate for Payer: GEHA Commercial |
$1,361.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,750.50
|
| Rate for Payer: Multiplan All |
$1,769.95
|
| Rate for Payer: OMNI Networks Commercial |
$1,361.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,750.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,847.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,458.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,808.85
|
| Rate for Payer: Zelis Auto |
$778.00
|
| Rate for Payer: Zelis Worker's Compensation |
$226.84
|
|
|
US REPAIR PSUEDO AN
|
Facility
|
OP
|
$1,945.00
|
|
|
Service Code
|
CPT 76936
|
| Hospital Charge Code |
2600543
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$128.76 |
| Max. Negotiated Rate |
$1,847.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,167.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$128.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$1,167.00
|
| Rate for Payer: Cash Price |
$1,167.00
|
| Rate for Payer: Cigna Commercial |
$1,653.25
|
| Rate for Payer: First Health Commercial |
$1,750.50
|
| Rate for Payer: First Health Workers Compensation |
$320.81
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,750.50
|
| Rate for Payer: GEHA Commercial |
$1,556.00
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,750.50
|
| Rate for Payer: Humana ChoiceCare |
$325.26
|
| Rate for Payer: Humana Medicare Advantage |
$295.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$496.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$131.39
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$1,769.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$1,361.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,750.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$151.70
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$131.39
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,847.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$1,458.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Commercial |
$1,653.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$131.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,808.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$778.00
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$226.84
|
|
|
US RETROPERITONEAL
|
Facility
|
IP
|
$1,258.00
|
|
|
Service Code
|
CPT 76770
|
| Hospital Charge Code |
2600121
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$99.23 |
| Max. Negotiated Rate |
$1,195.10 |
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cigna Commercial |
$1,069.30
|
| Rate for Payer: First Health Commercial |
$1,132.20
|
| Rate for Payer: First Health Workers Compensation |
$140.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,132.20
|
| Rate for Payer: GEHA Commercial |
$880.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,132.20
|
| Rate for Payer: Multiplan All |
$1,144.78
|
| Rate for Payer: OMNI Networks Commercial |
$880.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,132.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,195.10
|
| Rate for Payer: Three Rivers Provider Network All |
$943.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,169.94
|
| Rate for Payer: Zelis Auto |
$503.20
|
| Rate for Payer: Zelis Worker's Compensation |
$99.23
|
|
|
US RETROPERITONEAL
|
Facility
|
OP
|
$1,258.00
|
|
|
Service Code
|
CPT 76770
|
| Hospital Charge Code |
2600121
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$1,195.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$754.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cigna Commercial |
$1,069.30
|
| Rate for Payer: First Health Commercial |
$1,132.20
|
| Rate for Payer: First Health Workers Compensation |
$140.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,132.20
|
| Rate for Payer: GEHA Commercial |
$1,006.40
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,132.20
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,144.78
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$880.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,132.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,195.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$943.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$1,069.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,169.94
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$503.20
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$99.23
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE LMT
|
Facility
|
IP
|
$983.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
8900020
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$933.85 |
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cigna Commercial |
$835.55
|
| Rate for Payer: First Health Commercial |
$884.70
|
| Rate for Payer: First Health Workers Compensation |
$104.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$884.70
|
| Rate for Payer: GEHA Commercial |
$688.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$884.70
|
| Rate for Payer: Multiplan All |
$894.53
|
| Rate for Payer: OMNI Networks Commercial |
$688.10
|
| Rate for Payer: One Health Plan PPO/POS |
$884.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$933.85
|
| Rate for Payer: Three Rivers Provider Network All |
$737.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$914.19
|
| Rate for Payer: Zelis Auto |
$393.20
|
| Rate for Payer: Zelis Worker's Compensation |
$73.82
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE LMT
|
Facility
|
OP
|
$983.00
|
|
|
Service Code
|
CPT 76775
|
| Hospital Charge Code |
8900020
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$933.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$589.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cigna Commercial |
$835.55
|
| Rate for Payer: First Health Commercial |
$884.70
|
| Rate for Payer: First Health Workers Compensation |
$104.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$884.70
|
| Rate for Payer: GEHA Commercial |
$786.40
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$884.70
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$894.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$688.10
|
| Rate for Payer: One Health Plan PPO/POS |
$884.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$933.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$737.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$835.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$914.19
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$393.20
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$73.82
|
|
|
US SACRAL DIMPLE (INFANT)
|
Facility
|
OP
|
$424.68
|
|
|
Service Code
|
CPT 76800
|
| Hospital Charge Code |
2676800
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$403.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$137.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$254.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$137.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$108.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$254.81
|
| Rate for Payer: Cash Price |
$254.81
|
| Rate for Payer: Cigna Commercial |
$360.98
|
| Rate for Payer: First Health Commercial |
$382.21
|
| Rate for Payer: First Health Workers Compensation |
$181.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$382.21
|
| Rate for Payer: GEHA Commercial |
$339.74
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$382.21
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$111.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$386.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$297.28
|
| Rate for Payer: One Health Plan PPO/POS |
$382.21
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$128.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$111.14
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$403.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$318.51
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$360.98
|
| Rate for Payer: United Healthcare Managed Medicaid |
$111.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$394.95
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$169.87
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$128.41
|
|
|
US SACRAL DIMPLE (INFANT)
|
Facility
|
IP
|
$424.68
|
|
|
Service Code
|
CPT 76800
|
| Hospital Charge Code |
2676800
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$128.41 |
| Max. Negotiated Rate |
$403.45 |
| Rate for Payer: Cash Price |
$254.81
|
| Rate for Payer: Cash Price |
$254.81
|
| Rate for Payer: Cigna Commercial |
$360.98
|
| Rate for Payer: First Health Commercial |
$382.21
|
| Rate for Payer: First Health Workers Compensation |
$181.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$382.21
|
| Rate for Payer: GEHA Commercial |
$297.28
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$382.21
|
| Rate for Payer: Multiplan All |
$386.46
|
| Rate for Payer: OMNI Networks Commercial |
$297.28
|
| Rate for Payer: One Health Plan PPO/POS |
$382.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$403.45
|
| Rate for Payer: Three Rivers Provider Network All |
$318.51
|
| Rate for Payer: United Payors & United Providers UP&UP |
$394.95
|
| Rate for Payer: Zelis Auto |
$169.87
|
| Rate for Payer: Zelis Worker's Compensation |
$128.41
|
|
|
US SCROTUM/TESTICULA
|
Facility
|
OP
|
$1,197.00
|
|
|
Service Code
|
CPT 76870
|
| Hospital Charge Code |
2600122
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$1,137.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$718.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cigna Commercial |
$1,017.45
|
| Rate for Payer: First Health Commercial |
$1,077.30
|
| Rate for Payer: First Health Workers Compensation |
$124.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,077.30
|
| Rate for Payer: GEHA Commercial |
$957.60
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,077.30
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,089.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$837.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,077.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,137.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$897.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$1,017.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,113.21
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$478.80
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$88.31
|
|
|
US SCROTUM/TESTICULA
|
Facility
|
IP
|
$1,197.00
|
|
|
Service Code
|
CPT 76870
|
| Hospital Charge Code |
2600122
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$88.31 |
| Max. Negotiated Rate |
$1,137.15 |
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cigna Commercial |
$1,017.45
|
| Rate for Payer: First Health Commercial |
$1,077.30
|
| Rate for Payer: First Health Workers Compensation |
$124.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,077.30
|
| Rate for Payer: GEHA Commercial |
$837.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,077.30
|
| Rate for Payer: Multiplan All |
$1,089.27
|
| Rate for Payer: OMNI Networks Commercial |
$837.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,077.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,137.15
|
| Rate for Payer: Three Rivers Provider Network All |
$897.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,113.21
|
| Rate for Payer: Zelis Auto |
$478.80
|
| Rate for Payer: Zelis Worker's Compensation |
$88.31
|
|
|
US SFT TIS HEAD & NK
|
Facility
|
IP
|
$1,148.50
|
|
|
Service Code
|
CPT 76536
|
| Hospital Charge Code |
2600248
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.06 |
| Max. Negotiated Rate |
$1,091.08 |
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$976.23
|
| Rate for Payer: First Health Commercial |
$1,033.65
|
| Rate for Payer: First Health Workers Compensation |
$138.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,033.65
|
| Rate for Payer: GEHA Commercial |
$803.95
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,033.65
|
| Rate for Payer: Multiplan All |
$1,045.13
|
| Rate for Payer: OMNI Networks Commercial |
$803.95
|
| Rate for Payer: One Health Plan PPO/POS |
$1,033.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,091.08
|
| Rate for Payer: Three Rivers Provider Network All |
$861.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,068.11
|
| Rate for Payer: Zelis Auto |
$459.40
|
| Rate for Payer: Zelis Worker's Compensation |
$98.06
|
|
|
US SFT TIS HEAD & NK
|
Facility
|
OP
|
$1,148.50
|
|
|
Service Code
|
CPT 76536
|
| Hospital Charge Code |
2600248
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$1,091.08 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$689.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cash Price |
$689.10
|
| Rate for Payer: Cigna Commercial |
$976.23
|
| Rate for Payer: First Health Commercial |
$1,033.65
|
| Rate for Payer: First Health Workers Compensation |
$138.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,033.65
|
| Rate for Payer: GEHA Commercial |
$918.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,033.65
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,045.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$803.95
|
| Rate for Payer: One Health Plan PPO/POS |
$1,033.65
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,091.08
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$861.38
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$976.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,068.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$459.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$98.06
|
|
|
US SINGLE ORG QUAD
|
Facility
|
IP
|
$1,185.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2666904
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.14 |
| Max. Negotiated Rate |
$1,125.75 |
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,007.25
|
| Rate for Payer: First Health Commercial |
$1,066.50
|
| Rate for Payer: First Health Workers Compensation |
$114.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,066.50
|
| Rate for Payer: GEHA Commercial |
$829.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,066.50
|
| Rate for Payer: Multiplan All |
$1,078.35
|
| Rate for Payer: OMNI Networks Commercial |
$829.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,066.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,125.75
|
| Rate for Payer: Three Rivers Provider Network All |
$888.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,102.05
|
| Rate for Payer: Zelis Auto |
$474.00
|
| Rate for Payer: Zelis Worker's Compensation |
$81.14
|
|
|
US SINGLE ORG QUAD
|
Facility
|
OP
|
$1,185.00
|
|
|
Service Code
|
CPT 76705
|
| Hospital Charge Code |
2666904
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.14 |
| Max. Negotiated Rate |
$1,125.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$711.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$145.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$115.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,007.25
|
| Rate for Payer: First Health Commercial |
$1,066.50
|
| Rate for Payer: First Health Workers Compensation |
$114.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,066.50
|
| Rate for Payer: GEHA Commercial |
$948.00
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,066.50
|
| Rate for Payer: Humana ChoiceCare |
$111.07
|
| Rate for Payer: Humana Medicare Advantage |
$100.97
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$169.63
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$117.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$1,078.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$829.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,066.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$136.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$117.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,125.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$888.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$1,007.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$117.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,102.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$474.00
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$81.14
|
|
|
US STRESS ECHO
|
Facility
|
IP
|
$2,882.00
|
|
|
Service Code
|
CPT 93350
|
| Hospital Charge Code |
2600547
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$786.79 |
| Max. Negotiated Rate |
$2,737.90 |
| Rate for Payer: Cash Price |
$1,729.20
|
| Rate for Payer: Cigna Commercial |
$2,449.70
|
| Rate for Payer: First Health Commercial |
$2,593.80
|
| Rate for Payer: First Health Workers Compensation |
$1,112.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,593.80
|
| Rate for Payer: GEHA Commercial |
$2,017.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,593.80
|
| Rate for Payer: Multiplan All |
$2,622.62
|
| Rate for Payer: OMNI Networks Commercial |
$2,017.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,593.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,737.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,161.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,680.26
|
| Rate for Payer: Zelis Auto |
$1,152.80
|
| Rate for Payer: Zelis Worker's Compensation |
$786.79
|
|
|
US STRESS ECHO
|
Facility
|
OP
|
$2,882.00
|
|
|
Service Code
|
CPT 93350
|
| Hospital Charge Code |
2600547
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$442.54 |
| Max. Negotiated Rate |
$2,737.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$676.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,729.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$676.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$535.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$520.63
|
| Rate for Payer: Cash Price |
$1,729.20
|
| Rate for Payer: Cash Price |
$1,729.20
|
| Rate for Payer: Cigna Commercial |
$2,449.70
|
| Rate for Payer: First Health Commercial |
$2,593.80
|
| Rate for Payer: First Health Workers Compensation |
$1,112.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,593.80
|
| Rate for Payer: GEHA Commercial |
$2,305.60
|
| Rate for Payer: GEHA Medicare |
$520.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,593.80
|
| Rate for Payer: Humana ChoiceCare |
$572.69
|
| Rate for Payer: Humana Medicare Advantage |
$520.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$874.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$546.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$520.63
|
| Rate for Payer: Multiplan All |
$2,622.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$885.07
|
| Rate for Payer: OMNI Networks Commercial |
$2,017.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,593.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$631.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$546.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$520.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,737.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,041.26
|
| Rate for Payer: Three Rivers Provider Network All |
$2,161.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$510.22
|
| Rate for Payer: United Healthcare Commercial |
$2,449.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$546.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$520.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,680.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$520.63
|
| Rate for Payer: Zelis Auto |
$1,152.80
|
| Rate for Payer: Zelis Medicare |
$442.54
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$624.76
|
| Rate for Payer: Zelis Worker's Compensation |
$786.79
|
|
|
USTEKINUMAB 130MG/26ML VIAL PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
3303208
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$298.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$245.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$245.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$194.25
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$149.40
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: GEHA Medicare |
$149.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$164.34
|
| Rate for Payer: Humana Medicare Advantage |
$149.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$250.99
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$198.21
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$149.40
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$253.98
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$228.86
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$198.21
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$149.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$298.80
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$146.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$198.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$149.40
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Medicare |
$126.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$179.28
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
USTEKINUMAB 130MG/26ML VIAL PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
3303208
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
USTEKINUMAB 520 MG/NS 250 ML IVPB PT OWN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303219
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
USTEKINUMAB 520 MG/NS 250 ML IVPB PT OWN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 99999999999
|
| Hospital Charge Code |
3303219
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
US THORACENTESIS (NON-RAD)
|
Facility
|
OP
|
$1,320.00
|
|
|
Service Code
|
CPT 76942
|
| Hospital Charge Code |
2600123
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$1,254.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$1,122.00
|
| Rate for Payer: First Health Commercial |
$1,188.00
|
| Rate for Payer: First Health Workers Compensation |
$117.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,188.00
|
| Rate for Payer: GEHA Commercial |
$1,056.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,188.00
|
| Rate for Payer: Humana ChoiceCare |
$343.20
|
| Rate for Payer: Multiplan All |
$1,201.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$792.00
|
| Rate for Payer: OMNI Networks Commercial |
$924.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,188.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,254.00
|
| Rate for Payer: Three Rivers Provider Network All |
$990.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,161.60
|
| Rate for Payer: United Healthcare Commercial |
$1,122.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$330.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,227.60
|
| Rate for Payer: Zelis Auto |
$528.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$660.00
|
| Rate for Payer: Zelis Worker's Compensation |
$83.26
|
|
