|
CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
CPT 26755
|
| Hospital Charge Code |
8899225
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$260.71 |
| Max. Negotiated Rate |
$907.25 |
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$811.75
|
| Rate for Payer: First Health Commercial |
$859.50
|
| Rate for Payer: First Health Workers Compensation |
$368.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$859.50
|
| Rate for Payer: GEHA Commercial |
$668.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$859.50
|
| Rate for Payer: Multiplan All |
$869.05
|
| Rate for Payer: OMNI Networks Commercial |
$668.50
|
| Rate for Payer: One Health Plan PPO/POS |
$859.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$907.25
|
| Rate for Payer: Three Rivers Provider Network All |
$716.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$888.15
|
| Rate for Payer: Zelis Auto |
$382.00
|
| Rate for Payer: Zelis Worker's Compensation |
$260.71
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA
|
Facility
|
IP
|
$683.00
|
|
|
Service Code
|
CPT 26755
|
| Hospital Charge Code |
6126755
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$186.46 |
| Max. Negotiated Rate |
$648.85 |
| Rate for Payer: Cash Price |
$409.80
|
| Rate for Payer: Cigna Commercial |
$580.55
|
| Rate for Payer: First Health Commercial |
$614.70
|
| Rate for Payer: First Health Workers Compensation |
$263.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$614.70
|
| Rate for Payer: GEHA Commercial |
$478.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$614.70
|
| Rate for Payer: Multiplan All |
$621.53
|
| Rate for Payer: OMNI Networks Commercial |
$478.10
|
| Rate for Payer: One Health Plan PPO/POS |
$614.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$648.85
|
| Rate for Payer: Three Rivers Provider Network All |
$512.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$635.19
|
| Rate for Payer: Zelis Auto |
$273.20
|
| Rate for Payer: Zelis Worker's Compensation |
$186.46
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
CPT 26755
|
| Hospital Charge Code |
8899225
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$907.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$573.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$811.75
|
| Rate for Payer: First Health Commercial |
$859.50
|
| Rate for Payer: First Health Workers Compensation |
$368.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$859.50
|
| Rate for Payer: GEHA Commercial |
$764.00
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$859.50
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$869.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$668.50
|
| Rate for Payer: One Health Plan PPO/POS |
$859.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$907.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$716.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Commercial |
$811.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$888.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$382.00
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$260.71
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/O MAN EA
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
CPT 26750
|
| Hospital Charge Code |
6126750
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: First Health Workers Compensation |
$211.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$438.40
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$219.20
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$149.60
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/O MAN EA
|
Facility
|
IP
|
$606.00
|
|
|
Service Code
|
CPT 26750
|
| Hospital Charge Code |
10026750
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.44 |
| Max. Negotiated Rate |
$575.70 |
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$515.10
|
| Rate for Payer: First Health Commercial |
$545.40
|
| Rate for Payer: First Health Workers Compensation |
$233.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$545.40
|
| Rate for Payer: GEHA Commercial |
$424.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$545.40
|
| Rate for Payer: Multiplan All |
$551.46
|
| Rate for Payer: OMNI Networks Commercial |
$424.20
|
| Rate for Payer: One Health Plan PPO/POS |
$545.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$575.70
|
| Rate for Payer: Three Rivers Provider Network All |
$454.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$563.58
|
| Rate for Payer: Zelis Auto |
$242.40
|
| Rate for Payer: Zelis Worker's Compensation |
$165.44
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/O MAN EA
|
Facility
|
OP
|
$1,051.00
|
|
| Hospital Charge Code |
8150075
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$262.75 |
| Max. Negotiated Rate |
$998.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$630.60
|
| Rate for Payer: Cash Price |
$630.60
|
| Rate for Payer: Cigna Commercial |
$893.35
|
| Rate for Payer: First Health Commercial |
$945.90
|
| Rate for Payer: First Health Workers Compensation |
$405.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$945.90
|
| Rate for Payer: GEHA Commercial |
$840.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$945.90
|
| Rate for Payer: Humana ChoiceCare |
$273.26
|
| Rate for Payer: Multiplan All |
$956.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$630.60
|
| Rate for Payer: OMNI Networks Commercial |
$735.70
|
| Rate for Payer: One Health Plan PPO/POS |
$945.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$998.45
|
| Rate for Payer: Three Rivers Provider Network All |
$788.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$924.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$262.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$977.43
|
| Rate for Payer: Zelis Auto |
$420.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$525.50
|
| Rate for Payer: Zelis Worker's Compensation |
$286.92
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/O MAN EA
|
Facility
|
IP
|
$1,051.00
|
|
| Hospital Charge Code |
8150075
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$286.92 |
| Max. Negotiated Rate |
$998.45 |
| Rate for Payer: Cash Price |
$630.60
|
| Rate for Payer: Cigna Commercial |
$893.35
|
| Rate for Payer: First Health Commercial |
$945.90
|
| Rate for Payer: First Health Workers Compensation |
$405.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$945.90
|
| Rate for Payer: GEHA Commercial |
$735.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$945.90
|
| Rate for Payer: Multiplan All |
$956.41
|
| Rate for Payer: OMNI Networks Commercial |
$735.70
|
| Rate for Payer: One Health Plan PPO/POS |
$945.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$998.45
|
| Rate for Payer: Three Rivers Provider Network All |
$788.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$977.43
|
| Rate for Payer: Zelis Auto |
$420.40
|
| Rate for Payer: Zelis Worker's Compensation |
$286.92
|
|
|
CLTX DSTL PHLNGL FX FNGR/THMB W/O MAN EA
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
CPT 26750
|
| Hospital Charge Code |
6126750
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: First Health Workers Compensation |
$211.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$383.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: Zelis Auto |
$219.20
|
| Rate for Payer: Zelis Worker's Compensation |
$149.60
|
|
|
CLTX FEM SHFT FX W/MAN W/WO SKIN/SKELET
|
Facility
|
OP
|
$5,823.00
|
|
|
Service Code
|
CPT 27502
|
| Hospital Charge Code |
8127502
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,291.70 |
| Max. Negotiated Rate |
$5,531.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,860.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,493.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,860.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,473.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,519.65
|
| Rate for Payer: Cash Price |
$3,493.80
|
| Rate for Payer: Cash Price |
$3,493.80
|
| Rate for Payer: Cigna Commercial |
$4,949.55
|
| Rate for Payer: First Health Commercial |
$5,240.70
|
| Rate for Payer: First Health Workers Compensation |
$2,248.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,240.70
|
| Rate for Payer: GEHA Commercial |
$4,658.40
|
| Rate for Payer: GEHA Medicare |
$1,519.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,240.70
|
| Rate for Payer: Humana ChoiceCare |
$1,671.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,519.65
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,553.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,503.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,519.65
|
| Rate for Payer: Multiplan All |
$5,298.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,583.41
|
| Rate for Payer: OMNI Networks Commercial |
$4,076.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,240.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,736.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,503.51
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,519.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,531.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,039.30
|
| Rate for Payer: Three Rivers Provider Network All |
$4,367.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,489.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,503.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,519.65
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,415.39
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,519.65
|
| Rate for Payer: Zelis Auto |
$2,329.20
|
| Rate for Payer: Zelis Medicare |
$1,291.70
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,823.58
|
| Rate for Payer: Zelis Worker's Compensation |
$1,589.68
|
|
|
CLTX FEM SHFT FX W/MAN W/WO SKIN/SKELET
|
Facility
|
IP
|
$5,823.00
|
|
|
Service Code
|
CPT 27502
|
| Hospital Charge Code |
8127502
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,589.68 |
| Max. Negotiated Rate |
$5,531.85 |
| Rate for Payer: Cash Price |
$3,493.80
|
| Rate for Payer: Cigna Commercial |
$4,949.55
|
| Rate for Payer: First Health Commercial |
$5,240.70
|
| Rate for Payer: First Health Workers Compensation |
$2,248.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,240.70
|
| Rate for Payer: GEHA Commercial |
$4,076.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,240.70
|
| Rate for Payer: Multiplan All |
$5,298.93
|
| Rate for Payer: OMNI Networks Commercial |
$4,076.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,240.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,531.85
|
| Rate for Payer: Three Rivers Provider Network All |
$4,367.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,415.39
|
| Rate for Payer: Zelis Auto |
$2,329.20
|
| Rate for Payer: Zelis Worker's Compensation |
$1,589.68
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
8300034
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| 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 |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| 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 |
$205.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$477.90
|
| Rate for Payer: GEHA Commercial |
$424.80
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$477.90
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$483.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| 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 |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$504.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$398.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$493.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$212.40
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
8728495
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$144.96 |
| Max. Negotiated Rate |
$504.45 |
| 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 |
$205.02
|
| 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 |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
6128495
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| 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 |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| 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 |
$205.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$477.90
|
| Rate for Payer: GEHA Commercial |
$424.80
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$477.90
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$483.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| 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 |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$504.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$398.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$493.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$212.40
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
6128495
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$144.96 |
| Max. Negotiated Rate |
$504.45 |
| 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 |
$205.02
|
| 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 |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
8728495
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| 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 |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| 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 |
$205.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$477.90
|
| Rate for Payer: GEHA Commercial |
$424.80
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$477.90
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$483.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| 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 |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$504.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$398.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$493.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$212.40
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/MANJ
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 28495
|
| Hospital Charge Code |
8300034
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$144.96 |
| Max. Negotiated Rate |
$504.45 |
| 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 |
$205.02
|
| 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 |
$144.96
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
8728490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$455.56 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$345.60
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
IP
|
$678.50
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
9628490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.23 |
| Max. Negotiated Rate |
$644.58 |
| Rate for Payer: Cash Price |
$407.10
|
| Rate for Payer: Cigna Commercial |
$576.73
|
| Rate for Payer: First Health Commercial |
$610.65
|
| Rate for Payer: First Health Workers Compensation |
$261.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$610.65
|
| Rate for Payer: GEHA Commercial |
$474.95
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$610.65
|
| Rate for Payer: Multiplan All |
$617.43
|
| Rate for Payer: OMNI Networks Commercial |
$474.95
|
| Rate for Payer: One Health Plan PPO/POS |
$610.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$644.58
|
| Rate for Payer: Three Rivers Provider Network All |
$508.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$631.00
|
| Rate for Payer: Zelis Auto |
$271.40
|
| Rate for Payer: Zelis Worker's Compensation |
$185.23
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
8728490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$302.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
8300033
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$455.56 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$345.60
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
6128490
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$455.56 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$345.60
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
6128490
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$302.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
8300033
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: First Health Commercial |
$388.80
|
| Rate for Payer: First Health Workers Compensation |
$166.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$388.80
|
| Rate for Payer: GEHA Commercial |
$302.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$388.80
|
| Rate for Payer: Multiplan All |
$393.12
|
| Rate for Payer: OMNI Networks Commercial |
$302.40
|
| Rate for Payer: One Health Plan PPO/POS |
$388.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$410.40
|
| Rate for Payer: Three Rivers Provider Network All |
$324.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$401.76
|
| Rate for Payer: Zelis Auto |
$172.80
|
| Rate for Payer: Zelis Worker's Compensation |
$117.94
|
|
|
CLTX FX GRT TOE PHLX/PHLG W/O MANJ
|
Facility
|
OP
|
$678.50
|
|
|
Service Code
|
CPT 28490
|
| Hospital Charge Code |
9628490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.77 |
| Max. Negotiated Rate |
$644.58 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$407.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$407.10
|
| Rate for Payer: Cash Price |
$407.10
|
| Rate for Payer: Cigna Commercial |
$576.73
|
| Rate for Payer: First Health Commercial |
$610.65
|
| Rate for Payer: First Health Workers Compensation |
$261.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$610.65
|
| Rate for Payer: GEHA Commercial |
$542.80
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$610.65
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$617.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$474.95
|
| Rate for Payer: One Health Plan PPO/POS |
$610.65
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$644.58
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$508.88
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$631.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$271.40
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$185.23
|
|
|
CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
CPT 28515
|
| Hospital Charge Code |
8300036
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$131.59 |
| Max. Negotiated Rate |
$457.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$289.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$167.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$132.77
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$227.78
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cigna Commercial |
$409.70
|
| Rate for Payer: First Health Commercial |
$433.80
|
| Rate for Payer: First Health Workers Compensation |
$186.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$433.80
|
| Rate for Payer: GEHA Commercial |
$385.60
|
| Rate for Payer: GEHA Medicare |
$227.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$433.80
|
| Rate for Payer: Humana ChoiceCare |
$250.56
|
| Rate for Payer: Humana Medicare Advantage |
$227.78
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$382.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$135.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$227.78
|
| Rate for Payer: Multiplan All |
$438.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$387.23
|
| Rate for Payer: OMNI Networks Commercial |
$337.40
|
| Rate for Payer: One Health Plan PPO/POS |
$433.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$156.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$135.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$227.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$457.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$455.56
|
| Rate for Payer: Three Rivers Provider Network All |
$361.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.22
|
| Rate for Payer: United Healthcare Managed Medicaid |
$135.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$448.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$227.78
|
| Rate for Payer: Zelis Auto |
$192.80
|
| Rate for Payer: Zelis Medicare |
$193.61
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$273.34
|
| Rate for Payer: Zelis Worker's Compensation |
$131.59
|
|
