|
DEPRESSION SCREEN ANNUAL SUBSEQUENT
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT G0444
|
| Hospital Charge Code |
9199502
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$29.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.41
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$59.36
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.41
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$20.75
|
|
|
DEPRESSION SCREEN ANNUAL SUBSEQUENT
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT G0444
|
| Hospital Charge Code |
9199502
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$29.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$20.75
|
|
|
DERMABRASION OTHER THAN FACE
|
Facility
|
OP
|
$892.00
|
|
|
Service Code
|
CPT 15782
|
| Hospital Charge Code |
6115782
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$243.52 |
| Max. Negotiated Rate |
$5,435.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$441.09
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$535.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$441.09
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$349.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,717.63
|
| Rate for Payer: Cash Price |
$535.20
|
| Rate for Payer: Cash Price |
$535.20
|
| Rate for Payer: Cigna Commercial |
$758.20
|
| Rate for Payer: First Health Commercial |
$802.80
|
| Rate for Payer: First Health Workers Compensation |
$344.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$802.80
|
| Rate for Payer: GEHA Commercial |
$713.60
|
| Rate for Payer: GEHA Medicare |
$2,717.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$802.80
|
| Rate for Payer: Humana ChoiceCare |
$2,989.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,717.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,565.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,717.63
|
| Rate for Payer: Multiplan All |
$811.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,619.97
|
| Rate for Payer: OMNI Networks Commercial |
$624.40
|
| Rate for Payer: One Health Plan PPO/POS |
$802.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$411.68
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$356.55
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,717.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$847.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,435.26
|
| Rate for Payer: Three Rivers Provider Network All |
$669.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,663.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,717.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$829.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,717.63
|
| Rate for Payer: Zelis Auto |
$356.80
|
| Rate for Payer: Zelis Medicare |
$2,309.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,261.16
|
| Rate for Payer: Zelis Worker's Compensation |
$243.52
|
|
|
DERMABRASION OTHER THAN FACE
|
Facility
|
IP
|
$892.00
|
|
|
Service Code
|
CPT 15782
|
| Hospital Charge Code |
6115782
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$243.52 |
| Max. Negotiated Rate |
$847.40 |
| Rate for Payer: Cash Price |
$535.20
|
| Rate for Payer: Cigna Commercial |
$758.20
|
| Rate for Payer: First Health Commercial |
$802.80
|
| Rate for Payer: First Health Workers Compensation |
$344.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$802.80
|
| Rate for Payer: GEHA Commercial |
$624.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$802.80
|
| Rate for Payer: Multiplan All |
$811.72
|
| Rate for Payer: OMNI Networks Commercial |
$624.40
|
| Rate for Payer: One Health Plan PPO/POS |
$802.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$847.40
|
| Rate for Payer: Three Rivers Provider Network All |
$669.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$829.56
|
| Rate for Payer: Zelis Auto |
$356.80
|
| Rate for Payer: Zelis Worker's Compensation |
$243.52
|
|
|
DERMABRASION TOTAL FACE
|
Facility
|
IP
|
$1,285.00
|
|
|
Service Code
|
CPT 15780
|
| Hospital Charge Code |
6115780
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$350.81 |
| Max. Negotiated Rate |
$1,220.75 |
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,092.25
|
| Rate for Payer: First Health Commercial |
$1,156.50
|
| Rate for Payer: First Health Workers Compensation |
$496.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,156.50
|
| Rate for Payer: GEHA Commercial |
$899.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,156.50
|
| Rate for Payer: Multiplan All |
$1,169.35
|
| Rate for Payer: OMNI Networks Commercial |
$899.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,156.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,220.75
|
| Rate for Payer: Three Rivers Provider Network All |
$963.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,195.05
|
| Rate for Payer: Zelis Auto |
$514.00
|
| Rate for Payer: Zelis Worker's Compensation |
$350.81
|
|
|
DERMABRASION TOTAL FACE
|
Facility
|
OP
|
$1,285.00
|
|
|
Service Code
|
CPT 15780
|
| Hospital Charge Code |
6115780
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$321.25 |
| Max. Negotiated Rate |
$5,435.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$771.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,717.63
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,092.25
|
| Rate for Payer: First Health Commercial |
$1,156.50
|
| Rate for Payer: First Health Workers Compensation |
$496.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,156.50
|
| Rate for Payer: GEHA Commercial |
$1,028.00
|
| Rate for Payer: GEHA Medicare |
$2,717.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,156.50
|
| Rate for Payer: Humana ChoiceCare |
$2,989.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,717.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,565.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,717.63
|
| Rate for Payer: Multiplan All |
$1,169.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,619.97
|
| Rate for Payer: OMNI Networks Commercial |
$899.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,156.50
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,717.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,220.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,435.26
|
| Rate for Payer: Three Rivers Provider Network All |
$963.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,663.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$321.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,717.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,195.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,717.63
|
| Rate for Payer: Zelis Auto |
$514.00
|
| Rate for Payer: Zelis Medicare |
$2,309.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,261.16
|
| Rate for Payer: Zelis Worker's Compensation |
$350.81
|
|
|
DERMA-FAT-FASCIA GRAFT
|
Facility
|
OP
|
$1,367.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
6115770
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$373.19 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$820.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$820.20
|
| Rate for Payer: Cash Price |
$820.20
|
| Rate for Payer: Cigna Commercial |
$1,161.95
|
| Rate for Payer: First Health Commercial |
$1,230.30
|
| Rate for Payer: First Health Workers Compensation |
$527.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,230.30
|
| Rate for Payer: GEHA Commercial |
$1,093.60
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,230.30
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,243.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$956.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,230.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,298.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,025.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,271.31
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$546.80
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$373.19
|
|
|
DERMA-FAT-FASCIA GRAFT
|
Facility
|
IP
|
$1,367.00
|
|
|
Service Code
|
CPT 15770
|
| Hospital Charge Code |
6115770
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$373.19 |
| Max. Negotiated Rate |
$1,298.65 |
| Rate for Payer: Cash Price |
$820.20
|
| Rate for Payer: Cigna Commercial |
$1,161.95
|
| Rate for Payer: First Health Commercial |
$1,230.30
|
| Rate for Payer: First Health Workers Compensation |
$527.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,230.30
|
| Rate for Payer: GEHA Commercial |
$956.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,230.30
|
| Rate for Payer: Multiplan All |
$1,243.97
|
| Rate for Payer: OMNI Networks Commercial |
$956.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,230.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,298.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,025.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,271.31
|
| Rate for Payer: Zelis Auto |
$546.80
|
| Rate for Payer: Zelis Worker's Compensation |
$373.19
|
|
|
DERMAGRAFT
|
Facility
|
IP
|
$4,339.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,184.55 |
| Max. Negotiated Rate |
$4,122.05 |
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cigna Commercial |
$3,688.15
|
| Rate for Payer: First Health Commercial |
$3,905.10
|
| Rate for Payer: First Health Workers Compensation |
$1,675.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,905.10
|
| Rate for Payer: GEHA Commercial |
$3,037.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,905.10
|
| Rate for Payer: Multiplan All |
$3,948.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,037.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,905.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,122.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,254.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,035.27
|
| Rate for Payer: Zelis Auto |
$1,735.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,184.55
|
|
|
DERMAGRAFT
|
Facility
|
OP
|
$4,339.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$4,122.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,603.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cigna Commercial |
$3,688.15
|
| Rate for Payer: First Health Commercial |
$3,905.10
|
| Rate for Payer: First Health Workers Compensation |
$1,675.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,905.10
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,905.10
|
| Rate for Payer: Humana ChoiceCare |
$1,128.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$3,948.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,603.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,037.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,905.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,122.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,254.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,818.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,035.27
|
| Rate for Payer: Zelis Auto |
$1,735.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,169.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,184.55
|
|
|
DERMAGRAFT
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT Q4106
|
| Hospital Charge Code |
1905280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.14 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: First Health Workers Compensation |
$73.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$133.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Worker's Compensation |
$52.14
|
|
|
DERMAGRAFT
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT Q4106
|
| Hospital Charge Code |
1905280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.66 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$67.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$67.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$53.40
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: First Health Workers Compensation |
$73.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$152.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Humana ChoiceCare |
$49.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$54.49
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.60
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$62.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$54.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$168.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$54.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$95.50
|
| Rate for Payer: Zelis Worker's Compensation |
$52.14
|
|
|
DERMAGRAFT 2 X 3 IN
|
Facility
|
OP
|
$4,339.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7005198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$4,122.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,603.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cigna Commercial |
$3,688.15
|
| Rate for Payer: First Health Commercial |
$3,905.10
|
| Rate for Payer: First Health Workers Compensation |
$1,675.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,905.10
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,905.10
|
| Rate for Payer: Humana ChoiceCare |
$1,128.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$3,948.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,603.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,037.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,905.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,122.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,254.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,818.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,035.27
|
| Rate for Payer: Zelis Auto |
$1,735.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,169.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,184.55
|
|
|
DERMAGRAFT 2 X 3 IN
|
Facility
|
IP
|
$4,339.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7005198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,184.55 |
| Max. Negotiated Rate |
$4,122.05 |
| Rate for Payer: Cash Price |
$2,603.40
|
| Rate for Payer: Cigna Commercial |
$3,688.15
|
| Rate for Payer: First Health Commercial |
$3,905.10
|
| Rate for Payer: First Health Workers Compensation |
$1,675.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,905.10
|
| Rate for Payer: GEHA Commercial |
$3,037.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,905.10
|
| Rate for Payer: Multiplan All |
$3,948.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,037.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,905.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,122.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,254.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,035.27
|
| Rate for Payer: Zelis Auto |
$1,735.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,184.55
|
|
|
dermatophagoides farinae IgE REF602475
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299143
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
dermatophagoides farinae IgE REF602475
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299143
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
dermatophagoides pteronyss IgE REF602467
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299142
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
dermatophagoides pteronyss IgE REF602467
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299142
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
DERM AUTOGRAFT FACE/NCK/HF/G
|
Facility
|
OP
|
$1,507.00
|
|
|
Service Code
|
CPT 15135
|
| Hospital Charge Code |
6115135
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$411.41 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$904.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$904.20
|
| Rate for Payer: Cash Price |
$904.20
|
| Rate for Payer: Cigna Commercial |
$1,280.95
|
| Rate for Payer: First Health Commercial |
$1,356.30
|
| Rate for Payer: First Health Workers Compensation |
$581.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,356.30
|
| Rate for Payer: GEHA Commercial |
$1,205.60
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,356.30
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,371.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,054.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,356.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,431.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,130.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,401.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$602.80
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$411.41
|
|
|
DERM AUTOGRAFT FACE/NCK/HF/G
|
Facility
|
IP
|
$1,507.00
|
|
|
Service Code
|
CPT 15135
|
| Hospital Charge Code |
6115135
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$411.41 |
| Max. Negotiated Rate |
$1,431.65 |
| Rate for Payer: Cash Price |
$904.20
|
| Rate for Payer: Cigna Commercial |
$1,280.95
|
| Rate for Payer: First Health Commercial |
$1,356.30
|
| Rate for Payer: First Health Workers Compensation |
$581.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,356.30
|
| Rate for Payer: GEHA Commercial |
$1,054.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,356.30
|
| Rate for Payer: Multiplan All |
$1,371.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,054.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,356.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,431.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,130.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,401.51
|
| Rate for Payer: Zelis Auto |
$602.80
|
| Rate for Payer: Zelis Worker's Compensation |
$411.41
|
|
|
DERM AUTOGRAFT F/N/HF/G ADD
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
CPT 15136
|
| Hospital Charge Code |
6115136
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$1,623.22 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$165.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$233.75
|
| Rate for Payer: First Health Commercial |
$247.50
|
| Rate for Payer: First Health Workers Compensation |
$106.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$247.50
|
| Rate for Payer: GEHA Commercial |
$220.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$247.50
|
| Rate for Payer: Humana ChoiceCare |
$71.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Multiplan All |
$250.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.00
|
| Rate for Payer: OMNI Networks Commercial |
$192.50
|
| Rate for Payer: One Health Plan PPO/POS |
$247.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$261.25
|
| Rate for Payer: Three Rivers Provider Network All |
$206.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$255.75
|
| Rate for Payer: Zelis Auto |
$110.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$137.50
|
| Rate for Payer: Zelis Worker's Compensation |
$75.08
|
|
|
DERM AUTOGRAFT F/N/HF/G ADD
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
CPT 15136
|
| Hospital Charge Code |
6115136
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$75.08 |
| Max. Negotiated Rate |
$261.25 |
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$233.75
|
| Rate for Payer: First Health Commercial |
$247.50
|
| Rate for Payer: First Health Workers Compensation |
$106.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$247.50
|
| Rate for Payer: GEHA Commercial |
$192.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$247.50
|
| Rate for Payer: Multiplan All |
$250.25
|
| Rate for Payer: OMNI Networks Commercial |
$192.50
|
| Rate for Payer: One Health Plan PPO/POS |
$247.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$261.25
|
| Rate for Payer: Three Rivers Provider Network All |
$206.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$255.75
|
| Rate for Payer: Zelis Auto |
$110.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.08
|
|
|
DERM AUTOGRAFT T/A/L ADD-ON
|
Facility
|
IP
|
$283.00
|
|
|
Service Code
|
CPT 15131
|
| Hospital Charge Code |
6115131
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$77.26 |
| Max. Negotiated Rate |
$268.85 |
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$240.55
|
| Rate for Payer: First Health Commercial |
$254.70
|
| Rate for Payer: First Health Workers Compensation |
$109.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$254.70
|
| Rate for Payer: GEHA Commercial |
$198.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$254.70
|
| Rate for Payer: Multiplan All |
$257.53
|
| Rate for Payer: OMNI Networks Commercial |
$198.10
|
| Rate for Payer: One Health Plan PPO/POS |
$254.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$268.85
|
| Rate for Payer: Three Rivers Provider Network All |
$212.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$263.19
|
| Rate for Payer: Zelis Auto |
$113.20
|
| Rate for Payer: Zelis Worker's Compensation |
$77.26
|
|
|
DERM AUTOGRAFT T/A/L ADD-ON
|
Facility
|
OP
|
$283.00
|
|
|
Service Code
|
CPT 15131
|
| Hospital Charge Code |
6115131
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$1,623.22 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$169.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$240.55
|
| Rate for Payer: First Health Commercial |
$254.70
|
| Rate for Payer: First Health Workers Compensation |
$109.27
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$254.70
|
| Rate for Payer: GEHA Commercial |
$226.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$254.70
|
| Rate for Payer: Humana ChoiceCare |
$73.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Multiplan All |
$257.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$169.80
|
| Rate for Payer: OMNI Networks Commercial |
$198.10
|
| Rate for Payer: One Health Plan PPO/POS |
$254.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$268.85
|
| Rate for Payer: Three Rivers Provider Network All |
$212.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$249.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$263.19
|
| Rate for Payer: Zelis Auto |
$113.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$141.50
|
| Rate for Payer: Zelis Worker's Compensation |
$77.26
|
|
|
DERM AUTOGRAFT TRNK/ARM/LEG
|
Facility
|
IP
|
$1,153.00
|
|
|
Service Code
|
CPT 15130
|
| Hospital Charge Code |
6115130
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$314.77 |
| Max. Negotiated Rate |
$1,095.35 |
| Rate for Payer: Cash Price |
$691.80
|
| Rate for Payer: Cigna Commercial |
$980.05
|
| Rate for Payer: First Health Commercial |
$1,037.70
|
| Rate for Payer: First Health Workers Compensation |
$445.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,037.70
|
| Rate for Payer: GEHA Commercial |
$807.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,037.70
|
| Rate for Payer: Multiplan All |
$1,049.23
|
| Rate for Payer: OMNI Networks Commercial |
$807.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,037.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,095.35
|
| Rate for Payer: Three Rivers Provider Network All |
$864.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,072.29
|
| Rate for Payer: Zelis Auto |
$461.20
|
| Rate for Payer: Zelis Worker's Compensation |
$314.77
|
|
