|
ESOPH ENDOSCOPY W/US FN BX
|
Facility
|
OP
|
$536.00
|
|
|
Service Code
|
CPT 43232
|
| Hospital Charge Code |
6143232
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$146.33 |
| Max. Negotiated Rate |
$3,602.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$321.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$700.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,801.27
|
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Cigna Commercial |
$455.60
|
| Rate for Payer: First Health Commercial |
$482.40
|
| Rate for Payer: First Health Workers Compensation |
$206.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$482.40
|
| Rate for Payer: GEHA Commercial |
$428.80
|
| Rate for Payer: GEHA Medicare |
$1,801.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$482.40
|
| Rate for Payer: Humana ChoiceCare |
$1,981.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,801.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,026.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$714.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,801.27
|
| Rate for Payer: Multiplan All |
$487.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,062.16
|
| Rate for Payer: OMNI Networks Commercial |
$375.20
|
| Rate for Payer: One Health Plan PPO/POS |
$482.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$825.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$714.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,801.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$509.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,602.54
|
| Rate for Payer: Three Rivers Provider Network All |
$402.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,765.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$714.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,801.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$498.48
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,801.27
|
| Rate for Payer: Zelis Auto |
$214.40
|
| Rate for Payer: Zelis Medicare |
$1,531.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,161.52
|
| Rate for Payer: Zelis Worker's Compensation |
$146.33
|
|
|
ESOPH FUNDOPLASTY LAP
|
Facility
|
OP
|
$1,726.00
|
|
|
Service Code
|
CPT 43327
|
| Hospital Charge Code |
6143327
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$431.50 |
| Max. Negotiated Rate |
$1,639.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,035.60
|
| Rate for Payer: Cash Price |
$1,035.60
|
| Rate for Payer: Cigna Commercial |
$1,467.10
|
| Rate for Payer: First Health Commercial |
$1,553.40
|
| Rate for Payer: First Health Workers Compensation |
$666.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,553.40
|
| Rate for Payer: GEHA Commercial |
$1,380.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,553.40
|
| Rate for Payer: Humana ChoiceCare |
$448.76
|
| Rate for Payer: Multiplan All |
$1,570.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,035.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,208.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,553.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,639.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,294.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,518.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$431.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,605.18
|
| Rate for Payer: Zelis Auto |
$690.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$863.00
|
| Rate for Payer: Zelis Worker's Compensation |
$471.20
|
|
|
ESOPH FUNDOPLASTY LAP
|
Facility
|
IP
|
$1,726.00
|
|
|
Service Code
|
CPT 43327
|
| Hospital Charge Code |
6143327
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$471.20 |
| Max. Negotiated Rate |
$1,639.70 |
| Rate for Payer: Cash Price |
$1,035.60
|
| Rate for Payer: Cigna Commercial |
$1,467.10
|
| Rate for Payer: First Health Commercial |
$1,553.40
|
| Rate for Payer: First Health Workers Compensation |
$666.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,553.40
|
| Rate for Payer: GEHA Commercial |
$1,208.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,553.40
|
| Rate for Payer: Multiplan All |
$1,570.66
|
| Rate for Payer: OMNI Networks Commercial |
$1,208.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,553.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,639.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,294.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,605.18
|
| Rate for Payer: Zelis Auto |
$690.40
|
| Rate for Payer: Zelis Worker's Compensation |
$471.20
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
OP
|
$2,406.00
|
|
|
Service Code
|
CPT 43328
|
| Hospital Charge Code |
6143328
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$601.50 |
| Max. Negotiated Rate |
$2,285.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,443.60
|
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cigna Commercial |
$2,045.10
|
| Rate for Payer: First Health Commercial |
$2,165.40
|
| Rate for Payer: First Health Workers Compensation |
$928.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.40
|
| Rate for Payer: GEHA Commercial |
$1,924.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.40
|
| Rate for Payer: Humana ChoiceCare |
$625.56
|
| Rate for Payer: Multiplan All |
$2,189.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,443.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,285.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,117.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$601.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.58
|
| Rate for Payer: Zelis Auto |
$962.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,203.00
|
| Rate for Payer: Zelis Worker's Compensation |
$656.84
|
|
|
ESOPH FUNDOPLASTY THOR
|
Facility
|
IP
|
$2,406.00
|
|
|
Service Code
|
CPT 43328
|
| Hospital Charge Code |
6143328
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$656.84 |
| Max. Negotiated Rate |
$2,285.70 |
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cigna Commercial |
$2,045.10
|
| Rate for Payer: First Health Commercial |
$2,165.40
|
| Rate for Payer: First Health Workers Compensation |
$928.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.40
|
| Rate for Payer: GEHA Commercial |
$1,684.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.40
|
| Rate for Payer: Multiplan All |
$2,189.46
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,285.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.58
|
| Rate for Payer: Zelis Auto |
$962.40
|
| Rate for Payer: Zelis Worker's Compensation |
$656.84
|
|
|
ESOPH LENGTHENING
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 43338
|
| Hospital Charge Code |
6143338
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$102.10 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$317.90
|
| Rate for Payer: First Health Commercial |
$336.60
|
| Rate for Payer: First Health Workers Compensation |
$144.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$336.60
|
| Rate for Payer: GEHA Commercial |
$261.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$336.60
|
| Rate for Payer: Multiplan All |
$340.34
|
| Rate for Payer: OMNI Networks Commercial |
$261.80
|
| Rate for Payer: One Health Plan PPO/POS |
$336.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$355.30
|
| Rate for Payer: Three Rivers Provider Network All |
$280.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$347.82
|
| Rate for Payer: Zelis Auto |
$149.60
|
| Rate for Payer: Zelis Worker's Compensation |
$102.10
|
|
|
ESOPH LENGTHENING
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 43338
|
| Hospital Charge Code |
6143338
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$93.50 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$317.90
|
| Rate for Payer: First Health Commercial |
$336.60
|
| Rate for Payer: First Health Workers Compensation |
$144.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$336.60
|
| Rate for Payer: GEHA Commercial |
$299.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$336.60
|
| Rate for Payer: Humana ChoiceCare |
$97.24
|
| Rate for Payer: Multiplan All |
$340.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$224.40
|
| Rate for Payer: OMNI Networks Commercial |
$261.80
|
| Rate for Payer: One Health Plan PPO/POS |
$336.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$355.30
|
| Rate for Payer: Three Rivers Provider Network All |
$280.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$329.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$93.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$347.82
|
| Rate for Payer: Zelis Auto |
$149.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$187.00
|
| Rate for Payer: Zelis Worker's Compensation |
$102.10
|
|
|
ESOPH OPTICAL ENDOMICROSCOPY
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
CPT 43206
|
| Hospital Charge Code |
6143206
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.94 |
| Max. Negotiated Rate |
$420.85 |
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cigna Commercial |
$376.55
|
| Rate for Payer: First Health Commercial |
$398.70
|
| Rate for Payer: First Health Workers Compensation |
$171.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$398.70
|
| Rate for Payer: GEHA Commercial |
$310.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$398.70
|
| Rate for Payer: Multiplan All |
$403.13
|
| Rate for Payer: OMNI Networks Commercial |
$310.10
|
| Rate for Payer: One Health Plan PPO/POS |
$398.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$420.85
|
| Rate for Payer: Three Rivers Provider Network All |
$332.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.99
|
| Rate for Payer: Zelis Auto |
$177.20
|
| Rate for Payer: Zelis Worker's Compensation |
$120.94
|
|
|
ESOPH OPTICAL ENDOMICROSCOPY
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
CPT 43206
|
| Hospital Charge Code |
6143206
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.94 |
| Max. Negotiated Rate |
$3,602.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,314.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$265.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,314.02
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,040.96
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,801.27
|
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cigna Commercial |
$376.55
|
| Rate for Payer: First Health Commercial |
$398.70
|
| Rate for Payer: First Health Workers Compensation |
$171.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$398.70
|
| Rate for Payer: GEHA Commercial |
$354.40
|
| Rate for Payer: GEHA Medicare |
$1,801.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$398.70
|
| Rate for Payer: Humana ChoiceCare |
$1,981.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,801.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,026.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,062.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,801.27
|
| Rate for Payer: Multiplan All |
$403.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,062.16
|
| Rate for Payer: OMNI Networks Commercial |
$310.10
|
| Rate for Payer: One Health Plan PPO/POS |
$398.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,226.41
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,062.16
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,801.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$420.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,602.54
|
| Rate for Payer: Three Rivers Provider Network All |
$332.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,765.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,062.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,801.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,801.27
|
| Rate for Payer: Zelis Auto |
$177.20
|
| Rate for Payer: Zelis Medicare |
$1,531.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,161.52
|
| Rate for Payer: Zelis Worker's Compensation |
$120.94
|
|
|
ESOPH SCOPE W/SCLEROSIS INJ
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
CPT 43204
|
| Hospital Charge Code |
6143204
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.94 |
| Max. Negotiated Rate |
$420.85 |
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cigna Commercial |
$376.55
|
| Rate for Payer: First Health Commercial |
$398.70
|
| Rate for Payer: First Health Workers Compensation |
$171.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$398.70
|
| Rate for Payer: GEHA Commercial |
$310.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$398.70
|
| Rate for Payer: Multiplan All |
$403.13
|
| Rate for Payer: OMNI Networks Commercial |
$310.10
|
| Rate for Payer: One Health Plan PPO/POS |
$398.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$420.85
|
| Rate for Payer: Three Rivers Provider Network All |
$332.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.99
|
| Rate for Payer: Zelis Auto |
$177.20
|
| Rate for Payer: Zelis Worker's Compensation |
$120.94
|
|
|
ESOPH SCOPE W/SCLEROSIS INJ
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
CPT 43204
|
| Hospital Charge Code |
6143204
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$120.94 |
| Max. Negotiated Rate |
$3,602.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$265.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$700.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,801.27
|
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cash Price |
$265.80
|
| Rate for Payer: Cigna Commercial |
$376.55
|
| Rate for Payer: First Health Commercial |
$398.70
|
| Rate for Payer: First Health Workers Compensation |
$171.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$398.70
|
| Rate for Payer: GEHA Commercial |
$354.40
|
| Rate for Payer: GEHA Medicare |
$1,801.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$398.70
|
| Rate for Payer: Humana ChoiceCare |
$1,981.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,801.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,026.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$714.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,801.27
|
| Rate for Payer: Multiplan All |
$403.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,062.16
|
| Rate for Payer: OMNI Networks Commercial |
$310.10
|
| Rate for Payer: One Health Plan PPO/POS |
$398.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$825.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$714.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,801.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$420.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,602.54
|
| Rate for Payer: Three Rivers Provider Network All |
$332.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,765.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$714.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,801.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$411.99
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,801.27
|
| Rate for Payer: Zelis Auto |
$177.20
|
| Rate for Payer: Zelis Medicare |
$1,531.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,161.52
|
| Rate for Payer: Zelis Worker's Compensation |
$120.94
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 43201
|
| Hospital Charge Code |
6143201
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
ESOPH SCOPE W/SUBMUCOUS INJ
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 43201
|
| Hospital Charge Code |
6143201
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$3,602.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$884.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$700.56
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,801.27
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: GEHA Medicare |
$1,801.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$1,981.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,801.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,026.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$714.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,801.27
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,062.16
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$825.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$714.83
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,801.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,602.54
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,765.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$714.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,801.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,801.27
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Medicare |
$1,531.08
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,161.52
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
ESPHG DSTL 2/3 W/LAPS MOBLJ
|
Facility
|
IP
|
$11,534.00
|
|
|
Service Code
|
CPT 43287
|
| Hospital Charge Code |
6169673
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$3,148.78 |
| Max. Negotiated Rate |
$10,957.30 |
| Rate for Payer: Cash Price |
$6,920.40
|
| Rate for Payer: Cigna Commercial |
$9,803.90
|
| Rate for Payer: First Health Commercial |
$10,380.60
|
| Rate for Payer: First Health Workers Compensation |
$4,453.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,380.60
|
| Rate for Payer: GEHA Commercial |
$8,073.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,380.60
|
| Rate for Payer: Multiplan All |
$10,495.94
|
| Rate for Payer: OMNI Networks Commercial |
$8,073.80
|
| Rate for Payer: One Health Plan PPO/POS |
$10,380.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,957.30
|
| Rate for Payer: Three Rivers Provider Network All |
$8,650.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,726.62
|
| Rate for Payer: Zelis Auto |
$4,613.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3,148.78
|
|
|
ESPHG DSTL 2/3 W/LAPS MOBLJ
|
Facility
|
OP
|
$11,534.00
|
|
|
Service Code
|
CPT 43287
|
| Hospital Charge Code |
6169673
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,883.50 |
| Max. Negotiated Rate |
$10,957.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,920.40
|
| Rate for Payer: Cash Price |
$6,920.40
|
| Rate for Payer: Cigna Commercial |
$9,803.90
|
| Rate for Payer: First Health Commercial |
$10,380.60
|
| Rate for Payer: First Health Workers Compensation |
$4,453.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,380.60
|
| Rate for Payer: GEHA Commercial |
$9,227.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,380.60
|
| Rate for Payer: Humana ChoiceCare |
$2,998.84
|
| Rate for Payer: Multiplan All |
$10,495.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,920.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,073.80
|
| Rate for Payer: One Health Plan PPO/POS |
$10,380.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,957.30
|
| Rate for Payer: Three Rivers Provider Network All |
$8,650.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,149.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,883.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,726.62
|
| Rate for Payer: Zelis Auto |
$4,613.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,767.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3,148.78
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Facility
|
IP
|
$10,054.00
|
|
|
Service Code
|
CPT 43286
|
| Hospital Charge Code |
6169672
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,744.74 |
| Max. Negotiated Rate |
$9,551.30 |
| Rate for Payer: Cash Price |
$6,032.40
|
| Rate for Payer: Cigna Commercial |
$8,545.90
|
| Rate for Payer: First Health Commercial |
$9,048.60
|
| Rate for Payer: First Health Workers Compensation |
$3,881.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,048.60
|
| Rate for Payer: GEHA Commercial |
$7,037.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,048.60
|
| Rate for Payer: Multiplan All |
$9,149.14
|
| Rate for Payer: OMNI Networks Commercial |
$7,037.80
|
| Rate for Payer: One Health Plan PPO/POS |
$9,048.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,551.30
|
| Rate for Payer: Three Rivers Provider Network All |
$7,540.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,350.22
|
| Rate for Payer: Zelis Auto |
$4,021.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2,744.74
|
|
|
ESPHG TOT W/LAPS MOBLJ
|
Facility
|
OP
|
$10,054.00
|
|
|
Service Code
|
CPT 43286
|
| Hospital Charge Code |
6169672
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,513.50 |
| Max. Negotiated Rate |
$9,551.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,032.40
|
| Rate for Payer: Cash Price |
$6,032.40
|
| Rate for Payer: Cigna Commercial |
$8,545.90
|
| Rate for Payer: First Health Commercial |
$9,048.60
|
| Rate for Payer: First Health Workers Compensation |
$3,881.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,048.60
|
| Rate for Payer: GEHA Commercial |
$8,043.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,048.60
|
| Rate for Payer: Humana ChoiceCare |
$2,614.04
|
| Rate for Payer: Multiplan All |
$9,149.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,032.40
|
| Rate for Payer: OMNI Networks Commercial |
$7,037.80
|
| Rate for Payer: One Health Plan PPO/POS |
$9,048.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,551.30
|
| Rate for Payer: Three Rivers Provider Network All |
$7,540.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,847.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,513.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,350.22
|
| Rate for Payer: Zelis Auto |
$4,021.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,027.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,744.74
|
|
|
ESPH THRSC MOBLJ
|
Facility
|
OP
|
$11,988.00
|
|
|
Service Code
|
CPT 43288
|
| Hospital Charge Code |
6169674
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$2,997.00 |
| Max. Negotiated Rate |
$11,388.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,192.80
|
| Rate for Payer: Cash Price |
$7,192.80
|
| Rate for Payer: Cigna Commercial |
$10,189.80
|
| Rate for Payer: First Health Commercial |
$10,789.20
|
| Rate for Payer: First Health Workers Compensation |
$4,628.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,789.20
|
| Rate for Payer: GEHA Commercial |
$9,590.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,789.20
|
| Rate for Payer: Humana ChoiceCare |
$3,116.88
|
| Rate for Payer: Multiplan All |
$10,909.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,192.80
|
| Rate for Payer: OMNI Networks Commercial |
$8,391.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,789.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,388.60
|
| Rate for Payer: Three Rivers Provider Network All |
$8,991.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,549.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,997.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,148.84
|
| Rate for Payer: Zelis Auto |
$4,795.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,994.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3,272.72
|
|
|
ESPH THRSC MOBLJ
|
Facility
|
IP
|
$11,988.00
|
|
|
Service Code
|
CPT 43288
|
| Hospital Charge Code |
6169674
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$3,272.72 |
| Max. Negotiated Rate |
$11,388.60 |
| Rate for Payer: Cash Price |
$7,192.80
|
| Rate for Payer: Cigna Commercial |
$10,189.80
|
| Rate for Payer: First Health Commercial |
$10,789.20
|
| Rate for Payer: First Health Workers Compensation |
$4,628.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,789.20
|
| Rate for Payer: GEHA Commercial |
$8,391.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,789.20
|
| Rate for Payer: Multiplan All |
$10,909.08
|
| Rate for Payer: OMNI Networks Commercial |
$8,391.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,789.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,388.60
|
| Rate for Payer: Three Rivers Provider Network All |
$8,991.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,148.84
|
| Rate for Payer: Zelis Auto |
$4,795.20
|
| Rate for Payer: Zelis Worker's Compensation |
$3,272.72
|
|
|
ESTABLISH BRAIN CAVITY SHUNT
|
Facility
|
OP
|
$2,230.00
|
|
|
Service Code
|
CPT 62223
|
| Hospital Charge Code |
6162223
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$557.50 |
| Max. Negotiated Rate |
$2,118.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$1,895.50
|
| Rate for Payer: First Health Commercial |
$2,007.00
|
| Rate for Payer: First Health Workers Compensation |
$861.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,007.00
|
| Rate for Payer: GEHA Commercial |
$1,784.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,007.00
|
| Rate for Payer: Humana ChoiceCare |
$579.80
|
| Rate for Payer: Multiplan All |
$2,029.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,338.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,561.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,007.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,118.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,672.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,962.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$557.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,073.90
|
| Rate for Payer: Zelis Auto |
$892.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,115.00
|
| Rate for Payer: Zelis Worker's Compensation |
$608.79
|
|
|
ESTABLISH BRAIN CAVITY SHUNT
|
Facility
|
IP
|
$2,230.00
|
|
|
Service Code
|
CPT 62223
|
| Hospital Charge Code |
6162223
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$608.79 |
| Max. Negotiated Rate |
$2,118.50 |
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$1,895.50
|
| Rate for Payer: First Health Commercial |
$2,007.00
|
| Rate for Payer: First Health Workers Compensation |
$861.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,007.00
|
| Rate for Payer: GEHA Commercial |
$1,561.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,007.00
|
| Rate for Payer: Multiplan All |
$2,029.30
|
| Rate for Payer: OMNI Networks Commercial |
$1,561.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,007.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,118.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,672.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,073.90
|
| Rate for Payer: Zelis Auto |
$892.00
|
| Rate for Payer: Zelis Worker's Compensation |
$608.79
|
|
|
ESTABLISHED PREV MED 40-64 YRS
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
8599396
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
ESTABLISHED PREV MED 40-64 YRS
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
8599396
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
ESTABLISHED PREV MED 40-64 YRS
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
7299396
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
ESTABLISHED PREV MED 40-64 YRS
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
7299396
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
