|
XR L-SPINE COMP
|
Facility
|
IP
|
$974.00
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
2400026
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$925.30 |
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cigna Commercial |
$827.90
|
| Rate for Payer: First Health Commercial |
$876.60
|
| Rate for Payer: First Health Workers Compensation |
$61.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$876.60
|
| Rate for Payer: GEHA Commercial |
$681.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$876.60
|
| Rate for Payer: Multiplan All |
$886.34
|
| Rate for Payer: OMNI Networks Commercial |
$681.80
|
| Rate for Payer: One Health Plan PPO/POS |
$876.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$925.30
|
| Rate for Payer: Three Rivers Provider Network All |
$730.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$905.82
|
| Rate for Payer: Zelis Auto |
$389.60
|
| Rate for Payer: Zelis Worker's Compensation |
$43.55
|
|
|
XR L-SPINE COMP W/FL/EX
|
Facility
|
IP
|
$1,066.00
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
2400094
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.37 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: First Health Workers Compensation |
$75.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$746.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
| Rate for Payer: Zelis Worker's Compensation |
$53.37
|
|
|
XR L-SPINE COMP W/FL/EX
|
Facility
|
OP
|
$1,066.00
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
2400094
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.37 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$639.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: First Health Workers Compensation |
$75.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$852.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| 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 |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$906.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$426.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$53.37
|
|
|
XR L-SPINE FL/EX ONLY
|
Facility
|
IP
|
$654.00
|
|
|
Service Code
|
CPT 72120
|
| Hospital Charge Code |
2400025
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.06 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$555.90
|
| Rate for Payer: First Health Commercial |
$588.60
|
| Rate for Payer: First Health Workers Compensation |
$52.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$588.60
|
| Rate for Payer: GEHA Commercial |
$457.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$588.60
|
| Rate for Payer: Multiplan All |
$595.14
|
| Rate for Payer: OMNI Networks Commercial |
$457.80
|
| Rate for Payer: One Health Plan PPO/POS |
$588.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$621.30
|
| Rate for Payer: Three Rivers Provider Network All |
$490.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$608.22
|
| Rate for Payer: Zelis Auto |
$261.60
|
| Rate for Payer: Zelis Worker's Compensation |
$37.06
|
|
|
XR L-SPINE FL/EX ONLY
|
Facility
|
OP
|
$654.00
|
|
|
Service Code
|
CPT 72120
|
| Hospital Charge Code |
2400025
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.06 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$392.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$555.90
|
| Rate for Payer: First Health Commercial |
$588.60
|
| Rate for Payer: First Health Workers Compensation |
$52.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$588.60
|
| Rate for Payer: GEHA Commercial |
$523.20
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$588.60
|
| 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 |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$595.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$457.80
|
| Rate for Payer: One Health Plan PPO/POS |
$588.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$621.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$490.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$555.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$608.22
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$261.60
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$37.06
|
|
|
XR MANDIBLE 4+VWS
|
Facility
|
OP
|
$706.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
2400001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$670.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$423.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$600.10
|
| Rate for Payer: First Health Commercial |
$635.40
|
| Rate for Payer: First Health Workers Compensation |
$51.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$635.40
|
| Rate for Payer: GEHA Commercial |
$564.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$635.40
|
| 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 |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$642.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$494.20
|
| Rate for Payer: One Health Plan PPO/POS |
$635.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$670.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$529.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$600.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$656.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$282.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$36.76
|
|
|
XR MANDIBLE 4+VWS
|
Facility
|
IP
|
$706.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
2400001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$670.70 |
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$600.10
|
| Rate for Payer: First Health Commercial |
$635.40
|
| Rate for Payer: First Health Workers Compensation |
$51.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$635.40
|
| Rate for Payer: GEHA Commercial |
$494.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$635.40
|
| Rate for Payer: Multiplan All |
$642.46
|
| Rate for Payer: OMNI Networks Commercial |
$494.20
|
| Rate for Payer: One Health Plan PPO/POS |
$635.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$670.70
|
| Rate for Payer: Three Rivers Provider Network All |
$529.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$656.58
|
| Rate for Payer: Zelis Auto |
$282.40
|
| Rate for Payer: Zelis Worker's Compensation |
$36.76
|
|
|
XR MANDIBLE PARTIAL
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
2450100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cigna Commercial |
$451.35
|
| Rate for Payer: First Health Commercial |
$477.90
|
| Rate for Payer: First Health Workers Compensation |
$46.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$477.90
|
| Rate for Payer: GEHA Commercial |
$371.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$477.90
|
| Rate for Payer: Multiplan All |
$483.21
|
| Rate for Payer: OMNI Networks Commercial |
$371.70
|
| Rate for Payer: One Health Plan PPO/POS |
$477.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$504.45
|
| Rate for Payer: Three Rivers Provider Network All |
$398.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$493.83
|
| Rate for Payer: Zelis Auto |
$212.40
|
| Rate for Payer: Zelis Worker's Compensation |
$32.80
|
|
|
XR MANDIBLE PARTIAL
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
2450100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$318.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$83.61
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cigna Commercial |
$451.35
|
| Rate for Payer: First Health Commercial |
$477.90
|
| Rate for Payer: First Health Workers Compensation |
$46.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$477.90
|
| Rate for Payer: GEHA Commercial |
$424.80
|
| Rate for Payer: GEHA Medicare |
$83.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$477.90
|
| Rate for Payer: Humana ChoiceCare |
$91.97
|
| Rate for Payer: Humana Medicare Advantage |
$83.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$140.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$83.61
|
| Rate for Payer: Multiplan All |
$483.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$142.14
|
| Rate for Payer: OMNI Networks Commercial |
$371.70
|
| Rate for Payer: One Health Plan PPO/POS |
$477.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$83.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$83.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$504.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$167.22
|
| Rate for Payer: Three Rivers Provider Network All |
$398.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$451.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$493.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$83.61
|
| Rate for Payer: Zelis Auto |
$212.40
|
| Rate for Payer: Zelis Medicare |
$71.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$100.33
|
| Rate for Payer: Zelis Worker's Compensation |
$32.80
|
|
|
XR MASTOID 3+ VWS
|
Facility
|
OP
|
$476.00
|
|
|
Service Code
|
CPT 70130
|
| Hospital Charge Code |
2400003
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.16 |
| Max. Negotiated Rate |
$452.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$285.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$404.60
|
| Rate for Payer: First Health Commercial |
$428.40
|
| Rate for Payer: First Health Workers Compensation |
$75.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$428.40
|
| Rate for Payer: GEHA Commercial |
$380.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$428.40
|
| 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 |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$433.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$333.20
|
| Rate for Payer: One Health Plan PPO/POS |
$428.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$452.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$357.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$404.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$442.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$190.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$53.16
|
|
|
XR MASTOID 3+ VWS
|
Facility
|
IP
|
$476.00
|
|
|
Service Code
|
CPT 70130
|
| Hospital Charge Code |
2400003
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.16 |
| Max. Negotiated Rate |
$452.20 |
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$404.60
|
| Rate for Payer: First Health Commercial |
$428.40
|
| Rate for Payer: First Health Workers Compensation |
$75.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$428.40
|
| Rate for Payer: GEHA Commercial |
$333.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$428.40
|
| Rate for Payer: Multiplan All |
$433.16
|
| Rate for Payer: OMNI Networks Commercial |
$333.20
|
| Rate for Payer: One Health Plan PPO/POS |
$428.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$452.20
|
| Rate for Payer: Three Rivers Provider Network All |
$357.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$442.68
|
| Rate for Payer: Zelis Auto |
$190.40
|
| Rate for Payer: Zelis Worker's Compensation |
$53.16
|
|
|
XR MASTOIDS <3VWS
|
Facility
|
IP
|
$341.00
|
|
|
Service Code
|
CPT 70120
|
| Hospital Charge Code |
2400229
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$46.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$238.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Worker's Compensation |
$32.80
|
|
|
XR MASTOIDS <3VWS
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
CPT 70120
|
| Hospital Charge Code |
2400229
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$204.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$46.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$272.80
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| 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 |
$71.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$83.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$289.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$32.80
|
|
|
XR MYELOGRAM 2 OR MORE
|
Facility
|
IP
|
$4,376.00
|
|
|
Service Code
|
CPT 62305
|
| Hospital Charge Code |
2407205
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,194.65 |
| Max. Negotiated Rate |
$4,157.20 |
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$3,719.60
|
| Rate for Payer: First Health Commercial |
$3,938.40
|
| Rate for Payer: First Health Workers Compensation |
$1,689.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,938.40
|
| Rate for Payer: GEHA Commercial |
$3,063.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,938.40
|
| Rate for Payer: Multiplan All |
$3,982.16
|
| Rate for Payer: OMNI Networks Commercial |
$3,063.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,938.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,157.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,282.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,069.68
|
| Rate for Payer: Zelis Auto |
$1,750.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,194.65
|
|
|
XR MYELOGRAM 2 OR MORE
|
Facility
|
OP
|
$4,376.00
|
|
|
Service Code
|
CPT 62305
|
| Hospital Charge Code |
2407205
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$637.66 |
| Max. Negotiated Rate |
$4,157.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$921.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,625.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$921.06
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$729.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$750.19
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cigna Commercial |
$3,719.60
|
| Rate for Payer: First Health Commercial |
$3,938.40
|
| Rate for Payer: First Health Workers Compensation |
$1,689.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,938.40
|
| Rate for Payer: GEHA Commercial |
$3,500.80
|
| Rate for Payer: GEHA Medicare |
$750.19
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,938.40
|
| Rate for Payer: Humana ChoiceCare |
$825.21
|
| Rate for Payer: Humana Medicare Advantage |
$750.19
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,260.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$744.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$750.19
|
| Rate for Payer: Multiplan All |
$3,982.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,275.32
|
| Rate for Payer: OMNI Networks Commercial |
$3,063.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,938.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$859.66
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$744.52
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$750.19
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,157.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,500.38
|
| Rate for Payer: Three Rivers Provider Network All |
$3,282.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$735.19
|
| Rate for Payer: United Healthcare Commercial |
$3,719.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$744.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$750.19
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,069.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$750.19
|
| Rate for Payer: Zelis Auto |
$1,750.40
|
| Rate for Payer: Zelis Medicare |
$637.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$900.23
|
| Rate for Payer: Zelis Worker's Compensation |
$1,194.65
|
|
|
XR NASAL BONES COMP
|
Facility
|
IP
|
$596.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
2400005
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.52 |
| Max. Negotiated Rate |
$566.20 |
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$506.60
|
| Rate for Payer: First Health Commercial |
$536.40
|
| Rate for Payer: First Health Workers Compensation |
$45.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$536.40
|
| Rate for Payer: GEHA Commercial |
$417.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$536.40
|
| Rate for Payer: Multiplan All |
$542.36
|
| Rate for Payer: OMNI Networks Commercial |
$417.20
|
| Rate for Payer: One Health Plan PPO/POS |
$536.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$566.20
|
| Rate for Payer: Three Rivers Provider Network All |
$447.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$554.28
|
| Rate for Payer: Zelis Auto |
$238.40
|
| Rate for Payer: Zelis Worker's Compensation |
$32.52
|
|
|
XR NASAL BONES COMP
|
Facility
|
OP
|
$596.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
2400005
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.52 |
| Max. Negotiated Rate |
$566.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$357.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$83.61
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Cigna Commercial |
$506.60
|
| Rate for Payer: First Health Commercial |
$536.40
|
| Rate for Payer: First Health Workers Compensation |
$45.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$536.40
|
| Rate for Payer: GEHA Commercial |
$476.80
|
| Rate for Payer: GEHA Medicare |
$83.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$536.40
|
| Rate for Payer: Humana ChoiceCare |
$91.97
|
| Rate for Payer: Humana Medicare Advantage |
$83.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$140.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$83.61
|
| Rate for Payer: Multiplan All |
$542.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$142.14
|
| Rate for Payer: OMNI Networks Commercial |
$417.20
|
| Rate for Payer: One Health Plan PPO/POS |
$536.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$83.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$83.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$566.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$167.22
|
| Rate for Payer: Three Rivers Provider Network All |
$447.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$506.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$554.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$83.61
|
| Rate for Payer: Zelis Auto |
$238.40
|
| Rate for Payer: Zelis Medicare |
$71.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$100.33
|
| Rate for Payer: Zelis Worker's Compensation |
$32.52
|
|
|
XR NESPHROSTOMY/LOOPGRM
|
Facility
|
IP
|
$1,283.00
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
2400153
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$116.99 |
| Max. Negotiated Rate |
$1,218.85 |
| Rate for Payer: Cash Price |
$769.80
|
| Rate for Payer: Cash Price |
$769.80
|
| Rate for Payer: Cigna Commercial |
$1,090.55
|
| Rate for Payer: First Health Commercial |
$1,154.70
|
| Rate for Payer: First Health Workers Compensation |
$165.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,154.70
|
| Rate for Payer: GEHA Commercial |
$898.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,154.70
|
| Rate for Payer: Multiplan All |
$1,167.53
|
| Rate for Payer: OMNI Networks Commercial |
$898.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,154.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,218.85
|
| Rate for Payer: Three Rivers Provider Network All |
$962.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,193.19
|
| Rate for Payer: Zelis Auto |
$513.20
|
| Rate for Payer: Zelis Worker's Compensation |
$116.99
|
|
|
XR NESPHROSTOMY/LOOPGRM
|
Facility
|
OP
|
$1,283.00
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
2400153
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$116.99 |
| Max. Negotiated Rate |
$1,218.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$769.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$257.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$203.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$769.80
|
| Rate for Payer: Cash Price |
$769.80
|
| Rate for Payer: Cigna Commercial |
$1,090.55
|
| Rate for Payer: First Health Commercial |
$1,154.70
|
| Rate for Payer: First Health Workers Compensation |
$165.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,154.70
|
| Rate for Payer: GEHA Commercial |
$1,026.40
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,154.70
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$1,167.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$898.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,154.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$240.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,218.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$962.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$1,090.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,193.19
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$513.20
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$116.99
|
|
|
XR ONE VIEW SPINE
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
2472020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$294.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$89.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$70.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$83.61
|
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cigna Commercial |
$417.35
|
| Rate for Payer: First Health Commercial |
$441.90
|
| Rate for Payer: First Health Workers Compensation |
$29.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$441.90
|
| Rate for Payer: GEHA Commercial |
$392.80
|
| Rate for Payer: GEHA Medicare |
$83.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$441.90
|
| Rate for Payer: Humana ChoiceCare |
$91.97
|
| Rate for Payer: Humana Medicare Advantage |
$83.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$140.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$71.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$83.61
|
| Rate for Payer: Multiplan All |
$446.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$142.14
|
| Rate for Payer: OMNI Networks Commercial |
$343.70
|
| Rate for Payer: One Health Plan PPO/POS |
$441.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$83.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$71.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$83.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$466.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$167.22
|
| Rate for Payer: Three Rivers Provider Network All |
$368.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$417.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$71.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$456.63
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$83.61
|
| Rate for Payer: Zelis Auto |
$196.40
|
| Rate for Payer: Zelis Medicare |
$71.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$100.33
|
| Rate for Payer: Zelis Worker's Compensation |
$20.92
|
|
|
XR ONE VIEW SPINE
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
2472020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cash Price |
$294.60
|
| Rate for Payer: Cigna Commercial |
$417.35
|
| Rate for Payer: First Health Commercial |
$441.90
|
| Rate for Payer: First Health Workers Compensation |
$29.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$441.90
|
| Rate for Payer: GEHA Commercial |
$343.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$441.90
|
| Rate for Payer: Multiplan All |
$446.81
|
| Rate for Payer: OMNI Networks Commercial |
$343.70
|
| Rate for Payer: One Health Plan PPO/POS |
$441.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$466.45
|
| Rate for Payer: Three Rivers Provider Network All |
$368.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$456.63
|
| Rate for Payer: Zelis Auto |
$196.40
|
| Rate for Payer: Zelis Worker's Compensation |
$20.92
|
|
|
XR OPTIC FORAMINA
|
Facility
|
OP
|
$455.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
2400221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$432.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$273.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$83.61
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cigna Commercial |
$386.75
|
| Rate for Payer: First Health Commercial |
$409.50
|
| Rate for Payer: First Health Workers Compensation |
$45.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$409.50
|
| Rate for Payer: GEHA Commercial |
$364.00
|
| Rate for Payer: GEHA Medicare |
$83.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$409.50
|
| Rate for Payer: Humana ChoiceCare |
$91.97
|
| Rate for Payer: Humana Medicare Advantage |
$83.61
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$140.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$83.61
|
| Rate for Payer: Multiplan All |
$414.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$142.14
|
| Rate for Payer: OMNI Networks Commercial |
$318.50
|
| Rate for Payer: One Health Plan PPO/POS |
$409.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$83.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$432.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$167.22
|
| Rate for Payer: Three Rivers Provider Network All |
$341.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$386.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$423.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$83.61
|
| Rate for Payer: Zelis Auto |
$182.00
|
| Rate for Payer: Zelis Medicare |
$71.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$100.33
|
| Rate for Payer: Zelis Worker's Compensation |
$32.40
|
|
|
XR OPTIC FORAMINA
|
Facility
|
IP
|
$455.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
2400221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$432.25 |
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cigna Commercial |
$386.75
|
| Rate for Payer: First Health Commercial |
$409.50
|
| Rate for Payer: First Health Workers Compensation |
$45.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$409.50
|
| Rate for Payer: GEHA Commercial |
$318.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$409.50
|
| Rate for Payer: Multiplan All |
$414.05
|
| Rate for Payer: OMNI Networks Commercial |
$318.50
|
| Rate for Payer: One Health Plan PPO/POS |
$409.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$432.25
|
| Rate for Payer: Three Rivers Provider Network All |
$341.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$423.15
|
| Rate for Payer: Zelis Auto |
$182.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.40
|
|
|
XR ORBITS
|
Facility
|
OP
|
$724.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
2450000
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$687.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$434.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$142.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$112.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$100.97
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Cigna Commercial |
$615.40
|
| Rate for Payer: First Health Commercial |
$651.60
|
| Rate for Payer: First Health Workers Compensation |
$57.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$651.60
|
| Rate for Payer: GEHA Commercial |
$579.20
|
| Rate for Payer: GEHA Medicare |
$100.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$651.60
|
| 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 |
$115.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$100.97
|
| Rate for Payer: Multiplan All |
$658.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$171.65
|
| Rate for Payer: OMNI Networks Commercial |
$506.80
|
| Rate for Payer: One Health Plan PPO/POS |
$651.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$132.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$115.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$100.97
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$687.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$201.94
|
| Rate for Payer: Three Rivers Provider Network All |
$543.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.95
|
| Rate for Payer: United Healthcare Commercial |
$615.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$115.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$673.32
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$100.97
|
| Rate for Payer: Zelis Auto |
$289.60
|
| Rate for Payer: Zelis Medicare |
$85.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$121.16
|
| Rate for Payer: Zelis Worker's Compensation |
$40.76
|
|
|
XR ORBITS
|
Facility
|
IP
|
$724.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
2450000
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$687.80 |
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Cigna Commercial |
$615.40
|
| Rate for Payer: First Health Commercial |
$651.60
|
| Rate for Payer: First Health Workers Compensation |
$57.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$651.60
|
| Rate for Payer: GEHA Commercial |
$506.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$651.60
|
| Rate for Payer: Multiplan All |
$658.84
|
| Rate for Payer: OMNI Networks Commercial |
$506.80
|
| Rate for Payer: One Health Plan PPO/POS |
$651.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$687.80
|
| Rate for Payer: Three Rivers Provider Network All |
$543.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$673.32
|
| Rate for Payer: Zelis Auto |
$289.60
|
| Rate for Payer: Zelis Worker's Compensation |
$40.76
|
|
