|
DRESS AQUACEL AG NON BORDER 4X5
|
Facility
|
OP
|
$296.00
|
|
| Hospital Charge Code |
90030843
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$236.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Humana ChoiceCare |
$76.96
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$177.60
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$260.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.00
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
DRESS AQUACEL FAOM ADHE 4X4
|
Facility
|
OP
|
$296.00
|
|
| Hospital Charge Code |
90030839
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$236.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Humana ChoiceCare |
$76.96
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$177.60
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$260.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.00
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
DRESS AQUACEL FAOM ADHE 4X4
|
Facility
|
IP
|
$296.00
|
|
| Hospital Charge Code |
90030839
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
DRESSING CHANGE NOT FOR BURN
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
6115852
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$40.13 |
| Max. Negotiated Rate |
$139.65 |
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$124.95
|
| Rate for Payer: First Health Commercial |
$132.30
|
| Rate for Payer: First Health Workers Compensation |
$56.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$132.30
|
| Rate for Payer: GEHA Commercial |
$102.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$132.30
|
| Rate for Payer: Multiplan All |
$133.77
|
| Rate for Payer: OMNI Networks Commercial |
$102.90
|
| Rate for Payer: One Health Plan PPO/POS |
$132.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$139.65
|
| Rate for Payer: Three Rivers Provider Network All |
$110.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$136.71
|
| Rate for Payer: Zelis Auto |
$58.80
|
| Rate for Payer: Zelis Worker's Compensation |
$40.13
|
|
|
DRESSING CHANGE NOT FOR BURN
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 15852
|
| Hospital Charge Code |
6115852
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$40.13 |
| Max. Negotiated Rate |
$1,162.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$581.24
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$124.95
|
| Rate for Payer: First Health Commercial |
$132.30
|
| Rate for Payer: First Health Workers Compensation |
$56.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$132.30
|
| Rate for Payer: GEHA Commercial |
$117.60
|
| Rate for Payer: GEHA Medicare |
$581.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$132.30
|
| Rate for Payer: Humana ChoiceCare |
$639.36
|
| Rate for Payer: Humana Medicare Advantage |
$581.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$976.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$581.24
|
| Rate for Payer: Multiplan All |
$133.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$988.11
|
| Rate for Payer: OMNI Networks Commercial |
$102.90
|
| Rate for Payer: One Health Plan PPO/POS |
$132.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$581.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$139.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,162.48
|
| Rate for Payer: Three Rivers Provider Network All |
$110.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$569.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$136.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$581.24
|
| Rate for Payer: Zelis Auto |
$58.80
|
| Rate for Payer: Zelis Medicare |
$494.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$697.49
|
| Rate for Payer: Zelis Worker's Compensation |
$40.13
|
|
|
DRESSING CHG SIMPLE
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
6180023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.39 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$365.50
|
| Rate for Payer: First Health Commercial |
$387.00
|
| Rate for Payer: First Health Workers Compensation |
$166.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.00
|
| Rate for Payer: GEHA Commercial |
$301.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.00
|
| Rate for Payer: Multiplan All |
$391.30
|
| Rate for Payer: OMNI Networks Commercial |
$301.00
|
| Rate for Payer: One Health Plan PPO/POS |
$387.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$408.50
|
| Rate for Payer: Three Rivers Provider Network All |
$322.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$399.90
|
| Rate for Payer: Zelis Auto |
$172.00
|
| Rate for Payer: Zelis Worker's Compensation |
$117.39
|
|
|
DRESSING CHG SIMPLE
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
6180023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.50 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$258.00
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$365.50
|
| Rate for Payer: First Health Commercial |
$387.00
|
| Rate for Payer: First Health Workers Compensation |
$166.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.00
|
| Rate for Payer: GEHA Commercial |
$344.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.00
|
| Rate for Payer: Humana ChoiceCare |
$111.80
|
| Rate for Payer: Multiplan All |
$391.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$258.00
|
| Rate for Payer: OMNI Networks Commercial |
$301.00
|
| Rate for Payer: One Health Plan PPO/POS |
$387.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$408.50
|
| Rate for Payer: Three Rivers Provider Network All |
$322.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$378.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$107.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$399.90
|
| Rate for Payer: Zelis Auto |
$172.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$215.00
|
| Rate for Payer: Zelis Worker's Compensation |
$117.39
|
|
|
DRESSING GELFOAM SPONGE SZ100 8X12
|
Facility
|
OP
|
$380.00
|
|
| Hospital Charge Code |
90030833
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$95.00 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$228.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$304.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Humana ChoiceCare |
$98.80
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$228.00
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$334.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$95.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
DRESSING GELFOAM SPONGE SZ100 8X12
|
Facility
|
IP
|
$380.00
|
|
| Hospital Charge Code |
90030833
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$266.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
DRESSING GELFOAM SPONGE SZ 4 2CMX2CM
|
Facility
|
IP
|
$393.00
|
|
| Hospital Charge Code |
90030835
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$107.29 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$275.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
DRESSING GELFOAM SPONGE SZ 4 2CMX2CM
|
Facility
|
OP
|
$393.00
|
|
| Hospital Charge Code |
90030835
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.25 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$235.80
|
| Rate for Payer: Cash Price |
$235.80
|
| Rate for Payer: Cigna Commercial |
$334.05
|
| Rate for Payer: First Health Commercial |
$353.70
|
| Rate for Payer: First Health Workers Compensation |
$151.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$353.70
|
| Rate for Payer: GEHA Commercial |
$314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$353.70
|
| Rate for Payer: Humana ChoiceCare |
$102.18
|
| Rate for Payer: Multiplan All |
$357.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$235.80
|
| Rate for Payer: OMNI Networks Commercial |
$275.10
|
| Rate for Payer: One Health Plan PPO/POS |
$353.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$373.35
|
| Rate for Payer: Three Rivers Provider Network All |
$294.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$345.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$365.49
|
| Rate for Payer: Zelis Auto |
$157.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$196.50
|
| Rate for Payer: Zelis Worker's Compensation |
$107.29
|
|
|
DRESSING GELFOAM SPONGE SZ 50 80X62-1/2M
|
Facility
|
IP
|
$296.00
|
|
| Hospital Charge Code |
90030834
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$80.81 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
DRESSING GELFOAM SPONGE SZ 50 80X62-1/2M
|
Facility
|
OP
|
$296.00
|
|
| Hospital Charge Code |
90030834
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cigna Commercial |
$251.60
|
| Rate for Payer: First Health Commercial |
$266.40
|
| Rate for Payer: First Health Workers Compensation |
$114.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$266.40
|
| Rate for Payer: GEHA Commercial |
$236.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$266.40
|
| Rate for Payer: Humana ChoiceCare |
$76.96
|
| Rate for Payer: Multiplan All |
$269.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$177.60
|
| Rate for Payer: OMNI Networks Commercial |
$207.20
|
| Rate for Payer: One Health Plan PPO/POS |
$266.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$281.20
|
| Rate for Payer: Three Rivers Provider Network All |
$222.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$260.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$275.28
|
| Rate for Payer: Zelis Auto |
$118.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.00
|
| Rate for Payer: Zelis Worker's Compensation |
$80.81
|
|
|
DRESSING MEPILEX HEEL
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT A6214
|
| Hospital Charge Code |
7003384
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.10
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$80.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Humana ChoiceCare |
$26.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.45
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$88.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$50.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
DRESSING MEPILEX HEEL
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT A6214
|
| Hospital Charge Code |
7003384
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$70.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
|
DRESSING MEPILEX SACRUM
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT A6214
|
| Hospital Charge Code |
7003383
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$54.00
|
| Rate for Payer: First Health Workers Compensation |
$23.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.00
|
| Rate for Payer: GEHA Commercial |
$42.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.00
|
| Rate for Payer: Multiplan All |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$42.00
|
| Rate for Payer: One Health Plan PPO/POS |
$54.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.00
|
| Rate for Payer: Three Rivers Provider Network All |
$45.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$55.80
|
| Rate for Payer: Zelis Auto |
$24.00
|
| Rate for Payer: Zelis Worker's Compensation |
$16.38
|
|
|
DRESSING MEPILEX SACRUM
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT A6214
|
| Hospital Charge Code |
7003383
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.10
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$51.00
|
| Rate for Payer: First Health Commercial |
$54.00
|
| Rate for Payer: First Health Workers Compensation |
$23.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$54.00
|
| Rate for Payer: GEHA Commercial |
$48.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$54.00
|
| Rate for Payer: Humana ChoiceCare |
$15.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.45
|
| Rate for Payer: Multiplan All |
$54.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36.00
|
| Rate for Payer: OMNI Networks Commercial |
$42.00
|
| Rate for Payer: One Health Plan PPO/POS |
$54.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.15
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$57.00
|
| Rate for Payer: Three Rivers Provider Network All |
$45.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$52.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$55.80
|
| Rate for Payer: Zelis Auto |
$24.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30.00
|
| Rate for Payer: Zelis Worker's Compensation |
$16.38
|
|
|
DRESSNG CHNG (NOT FOR BURN) W/REG ANESTH
|
Facility
|
OP
|
$949.00
|
|
| Hospital Charge Code |
8115852
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$901.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$569.40
|
| Rate for Payer: Cash Price |
$569.40
|
| Rate for Payer: Cigna Commercial |
$806.65
|
| Rate for Payer: First Health Commercial |
$854.10
|
| Rate for Payer: First Health Workers Compensation |
$366.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$854.10
|
| Rate for Payer: GEHA Commercial |
$759.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$854.10
|
| Rate for Payer: Humana ChoiceCare |
$246.74
|
| Rate for Payer: Multiplan All |
$863.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$569.40
|
| Rate for Payer: OMNI Networks Commercial |
$664.30
|
| Rate for Payer: One Health Plan PPO/POS |
$854.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$901.55
|
| Rate for Payer: Three Rivers Provider Network All |
$711.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$835.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$237.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$882.57
|
| Rate for Payer: Zelis Auto |
$379.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$474.50
|
| Rate for Payer: Zelis Worker's Compensation |
$259.08
|
|
|
DRESSNG CHNG (NOT FOR BURN) W/REG ANESTH
|
Facility
|
IP
|
$949.00
|
|
| Hospital Charge Code |
8115852
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$259.08 |
| Max. Negotiated Rate |
$901.55 |
| Rate for Payer: Cash Price |
$569.40
|
| Rate for Payer: Cigna Commercial |
$806.65
|
| Rate for Payer: First Health Commercial |
$854.10
|
| Rate for Payer: First Health Workers Compensation |
$366.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$854.10
|
| Rate for Payer: GEHA Commercial |
$664.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$854.10
|
| Rate for Payer: Multiplan All |
$863.59
|
| Rate for Payer: OMNI Networks Commercial |
$664.30
|
| Rate for Payer: One Health Plan PPO/POS |
$854.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$901.55
|
| Rate for Payer: Three Rivers Provider Network All |
$711.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$882.57
|
| Rate for Payer: Zelis Auto |
$379.60
|
| Rate for Payer: Zelis Worker's Compensation |
$259.08
|
|
|
DRILL BIT STRYKER 2.5 X 216 DRILL
|
Facility
|
OP
|
$501.00
|
|
| Hospital Charge Code |
90070092
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$125.25 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$400.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Humana ChoiceCare |
$130.26
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$300.60
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$440.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$250.50
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
DRILL BIT STRYKER 2.5 X 216 DRILL
|
Facility
|
IP
|
$501.00
|
|
| Hospital Charge Code |
90070092
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$136.77 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$350.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
DRILL BIT STRYKER 3.1 X 216 DRILL
|
Facility
|
OP
|
$501.00
|
|
| Hospital Charge Code |
90070091
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$125.25 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$400.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Humana ChoiceCare |
$130.26
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$300.60
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$440.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$250.50
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
DRILL BIT STRYKER 3.1 X 216 DRILL
|
Facility
|
IP
|
$501.00
|
|
| Hospital Charge Code |
90070091
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$136.77 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$350.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
DRILL BIT STRYKER TOTAL KNEE
|
Facility
|
OP
|
$501.00
|
|
| Hospital Charge Code |
90070089
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$125.25 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$300.60
|
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$400.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Humana ChoiceCare |
$130.26
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$300.60
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$440.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$250.50
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
|
DRILL BIT STRYKER TOTAL KNEE
|
Facility
|
IP
|
$501.00
|
|
| Hospital Charge Code |
90070089
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$136.77 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Cash Price |
$300.60
|
| Rate for Payer: Cigna Commercial |
$425.85
|
| Rate for Payer: First Health Commercial |
$450.90
|
| Rate for Payer: First Health Workers Compensation |
$193.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$450.90
|
| Rate for Payer: GEHA Commercial |
$350.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$450.90
|
| Rate for Payer: Multiplan All |
$455.91
|
| Rate for Payer: OMNI Networks Commercial |
$350.70
|
| Rate for Payer: One Health Plan PPO/POS |
$450.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$475.95
|
| Rate for Payer: Three Rivers Provider Network All |
$375.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$465.93
|
| Rate for Payer: Zelis Auto |
$200.40
|
| Rate for Payer: Zelis Worker's Compensation |
$136.77
|
|
