|
EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1 CM
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
CPT 11401
|
| Hospital Charge Code |
9400014
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$123.67 |
| Max. Negotiated Rate |
$774.28 |
| Rate for Payer: Cigna Commercial |
$385.05
|
| Rate for Payer: First Health Commercial |
$407.70
|
| Rate for Payer: First Health Workers Compensation |
$174.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$407.70
|
| Rate for Payer: GEHA Commercial |
$362.40
|
| Rate for Payer: GEHA Medicare |
$387.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$407.70
|
| Rate for Payer: Humana ChoiceCare |
$425.85
|
| Rate for Payer: Humana Medicare Advantage |
$387.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$650.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$387.14
|
| Rate for Payer: Multiplan All |
$412.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$658.14
|
| Rate for Payer: OMNI Networks Commercial |
$317.10
|
| Rate for Payer: One Health Plan PPO/POS |
$407.70
|
| 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 |
$387.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$430.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$774.28
|
| Rate for Payer: Three Rivers Provider Network All |
$339.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$387.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$421.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$387.14
|
| Rate for Payer: Zelis Auto |
$181.20
|
| Rate for Payer: Zelis Medicare |
$329.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.57
|
| Rate for Payer: Zelis Worker's Compensation |
$123.67
|
| 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 |
$271.80
|
| 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 |
$387.14
|
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Cash Price |
$271.80
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1 CM
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
CPT 11401
|
| Hospital Charge Code |
6111401
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$87.36 |
| Max. Negotiated Rate |
$774.28 |
| 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 |
$192.00
|
| 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 |
$387.14
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$272.00
|
| Rate for Payer: First Health Commercial |
$288.00
|
| Rate for Payer: First Health Workers Compensation |
$123.55
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$288.00
|
| Rate for Payer: GEHA Commercial |
$256.00
|
| Rate for Payer: GEHA Medicare |
$387.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$288.00
|
| Rate for Payer: Humana ChoiceCare |
$425.85
|
| Rate for Payer: Humana Medicare Advantage |
$387.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$650.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$387.14
|
| Rate for Payer: Multiplan All |
$291.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$658.14
|
| Rate for Payer: OMNI Networks Commercial |
$224.00
|
| Rate for Payer: One Health Plan PPO/POS |
$288.00
|
| 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 |
$387.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$304.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$774.28
|
| Rate for Payer: Three Rivers Provider Network All |
$240.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$387.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$297.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$387.14
|
| Rate for Payer: Zelis Auto |
$128.00
|
| Rate for Payer: Zelis Medicare |
$329.07
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$464.57
|
| Rate for Payer: Zelis Worker's Compensation |
$87.36
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1 CM
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
CPT 11401
|
| Hospital Charge Code |
20300108
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$123.67 |
| Max. Negotiated Rate |
$430.35 |
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Cigna Commercial |
$385.05
|
| Rate for Payer: First Health Commercial |
$407.70
|
| Rate for Payer: First Health Workers Compensation |
$174.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$407.70
|
| Rate for Payer: GEHA Commercial |
$317.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$407.70
|
| Rate for Payer: Multiplan All |
$412.23
|
| Rate for Payer: OMNI Networks Commercial |
$317.10
|
| Rate for Payer: One Health Plan PPO/POS |
$407.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$430.35
|
| Rate for Payer: Three Rivers Provider Network All |
$339.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$421.29
|
| Rate for Payer: Zelis Auto |
$181.20
|
| Rate for Payer: Zelis Worker's Compensation |
$123.67
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1 CM
|
Facility
|
IP
|
$2,859.00
|
|
|
Service Code
|
CPT 11401
|
| Hospital Charge Code |
1911401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$780.51 |
| Max. Negotiated Rate |
$2,716.05 |
| Rate for Payer: Cash Price |
$1,715.40
|
| Rate for Payer: Cigna Commercial |
$2,430.15
|
| Rate for Payer: First Health Commercial |
$2,573.10
|
| Rate for Payer: First Health Workers Compensation |
$1,103.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,573.10
|
| Rate for Payer: GEHA Commercial |
$2,001.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,573.10
|
| Rate for Payer: Multiplan All |
$2,601.69
|
| Rate for Payer: OMNI Networks Commercial |
$2,001.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,573.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,716.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,144.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,658.87
|
| Rate for Payer: Zelis Auto |
$1,143.60
|
| Rate for Payer: Zelis Worker's Compensation |
$780.51
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$4,007.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
1911402
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$349.43 |
| Max. Negotiated Rate |
$3,806.65 |
| 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 |
$2,404.20
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$2,404.20
|
| Rate for Payer: Cash Price |
$2,404.20
|
| Rate for Payer: Cigna Commercial |
$3,405.95
|
| Rate for Payer: First Health Commercial |
$3,606.30
|
| Rate for Payer: First Health Workers Compensation |
$1,547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,606.30
|
| Rate for Payer: GEHA Commercial |
$3,205.60
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,606.30
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$3,646.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$2,804.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,606.30
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,806.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$3,005.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,726.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$1,602.80
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$1,093.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$472.20
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
8599499
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$448.59 |
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cigna Commercial |
$401.37
|
| Rate for Payer: First Health Commercial |
$424.98
|
| Rate for Payer: First Health Workers Compensation |
$182.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$424.98
|
| Rate for Payer: GEHA Commercial |
$330.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$424.98
|
| Rate for Payer: Multiplan All |
$429.70
|
| Rate for Payer: OMNI Networks Commercial |
$330.54
|
| Rate for Payer: One Health Plan PPO/POS |
$424.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$448.59
|
| Rate for Payer: Three Rivers Provider Network All |
$354.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.15
|
| Rate for Payer: Zelis Auto |
$188.88
|
| Rate for Payer: Zelis Worker's Compensation |
$128.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$4,007.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
1911402
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,093.91 |
| Max. Negotiated Rate |
$3,806.65 |
| Rate for Payer: Cash Price |
$2,404.20
|
| Rate for Payer: Cigna Commercial |
$3,405.95
|
| Rate for Payer: First Health Commercial |
$3,606.30
|
| Rate for Payer: First Health Workers Compensation |
$1,547.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,606.30
|
| Rate for Payer: GEHA Commercial |
$2,804.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,606.30
|
| Rate for Payer: Multiplan All |
$3,646.37
|
| Rate for Payer: OMNI Networks Commercial |
$2,804.90
|
| Rate for Payer: One Health Plan PPO/POS |
$3,606.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,806.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,005.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,726.51
|
| Rate for Payer: Zelis Auto |
$1,602.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,093.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
9400015
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$301.80
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$402.40
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
9400015
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$477.85 |
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$352.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
23500012
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$301.80
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$402.40
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$353.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
6111402
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$335.35 |
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$300.05
|
| Rate for Payer: First Health Commercial |
$317.70
|
| Rate for Payer: First Health Workers Compensation |
$136.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$317.70
|
| Rate for Payer: GEHA Commercial |
$247.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$317.70
|
| Rate for Payer: Multiplan All |
$321.23
|
| Rate for Payer: OMNI Networks Commercial |
$247.10
|
| Rate for Payer: One Health Plan PPO/POS |
$317.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$335.35
|
| Rate for Payer: Three Rivers Provider Network All |
$264.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$328.29
|
| Rate for Payer: Zelis Auto |
$141.20
|
| Rate for Payer: Zelis Worker's Compensation |
$96.37
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
23500012
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$477.85 |
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$352.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$472.20
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
7211402
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$283.32
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cigna Commercial |
$401.37
|
| Rate for Payer: First Health Commercial |
$424.98
|
| Rate for Payer: First Health Workers Compensation |
$182.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$424.98
|
| Rate for Payer: GEHA Commercial |
$377.76
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$424.98
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$429.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$330.54
|
| Rate for Payer: One Health Plan PPO/POS |
$424.98
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$448.59
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$354.15
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$188.88
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$128.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$472.20
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
8599499
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$283.32
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cigna Commercial |
$401.37
|
| Rate for Payer: First Health Commercial |
$424.98
|
| Rate for Payer: First Health Workers Compensation |
$182.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$424.98
|
| Rate for Payer: GEHA Commercial |
$377.76
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$424.98
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$429.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$330.54
|
| Rate for Payer: One Health Plan PPO/POS |
$424.98
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$448.59
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$354.15
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$188.88
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$128.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$353.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
6111402
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$211.80
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cash Price |
$211.80
|
| Rate for Payer: Cigna Commercial |
$300.05
|
| Rate for Payer: First Health Commercial |
$317.70
|
| Rate for Payer: First Health Workers Compensation |
$136.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$317.70
|
| Rate for Payer: GEHA Commercial |
$282.40
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$317.70
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$321.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$247.10
|
| Rate for Payer: One Health Plan PPO/POS |
$317.70
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$335.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$264.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$328.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$141.20
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$96.37
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
20300097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$1,363.52 |
| 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 |
$301.80
|
| 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 |
$681.76
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$402.40
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$356.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| 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 |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$356.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
20300097
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$477.85 |
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$427.55
|
| Rate for Payer: First Health Commercial |
$452.70
|
| Rate for Payer: First Health Workers Compensation |
$194.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$452.70
|
| Rate for Payer: GEHA Commercial |
$352.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$452.70
|
| Rate for Payer: Multiplan All |
$457.73
|
| Rate for Payer: OMNI Networks Commercial |
$352.10
|
| Rate for Payer: One Health Plan PPO/POS |
$452.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$477.85
|
| Rate for Payer: Three Rivers Provider Network All |
$377.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$467.79
|
| Rate for Payer: Zelis Auto |
$201.20
|
| Rate for Payer: Zelis Worker's Compensation |
$137.32
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2 CM
|
Facility
|
IP
|
$472.20
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
7211402
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$128.91 |
| Max. Negotiated Rate |
$448.59 |
| Rate for Payer: Cash Price |
$283.32
|
| Rate for Payer: Cigna Commercial |
$401.37
|
| Rate for Payer: First Health Commercial |
$424.98
|
| Rate for Payer: First Health Workers Compensation |
$182.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$424.98
|
| Rate for Payer: GEHA Commercial |
$330.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$424.98
|
| Rate for Payer: Multiplan All |
$429.70
|
| Rate for Payer: OMNI Networks Commercial |
$330.54
|
| Rate for Payer: One Health Plan PPO/POS |
$424.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$448.59
|
| Rate for Payer: Three Rivers Provider Network All |
$354.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$439.15
|
| Rate for Payer: Zelis Auto |
$188.88
|
| Rate for Payer: Zelis Worker's Compensation |
$128.91
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
OP
|
$549.63
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
8511403
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$1,363.52 |
| Rate for Payer: GEHA Commercial |
$439.70
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$329.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$657.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$681.76
|
| Rate for Payer: Cash Price |
$329.78
|
| Rate for Payer: Cash Price |
$329.78
|
| Rate for Payer: Cigna Commercial |
$467.19
|
| Rate for Payer: First Health Commercial |
$494.67
|
| Rate for Payer: First Health Workers Compensation |
$212.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$494.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$494.67
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$670.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$500.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$384.74
|
| Rate for Payer: One Health Plan PPO/POS |
$494.67
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$774.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$670.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$412.22
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$670.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$219.85
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$150.05
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
IP
|
$549.63
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
7211403
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$522.15 |
| Rate for Payer: Cash Price |
$329.78
|
| Rate for Payer: Cigna Commercial |
$467.19
|
| Rate for Payer: First Health Commercial |
$494.67
|
| Rate for Payer: First Health Workers Compensation |
$212.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$494.67
|
| Rate for Payer: GEHA Commercial |
$384.74
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$494.67
|
| Rate for Payer: Multiplan All |
$500.16
|
| Rate for Payer: OMNI Networks Commercial |
$384.74
|
| Rate for Payer: One Health Plan PPO/POS |
$494.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.15
|
| Rate for Payer: Three Rivers Provider Network All |
$412.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.16
|
| Rate for Payer: Zelis Auto |
$219.85
|
| Rate for Payer: Zelis Worker's Compensation |
$150.05
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
6111403
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$124.76 |
| Max. Negotiated Rate |
$1,363.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$274.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$657.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$681.76
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: First Health Workers Compensation |
$176.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$365.60
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$670.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$774.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$670.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$670.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$182.80
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$124.76
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
OP
|
$549.63
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
7211403
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$1,363.52 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$329.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$829.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$657.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$681.76
|
| Rate for Payer: Cash Price |
$329.78
|
| Rate for Payer: Cash Price |
$329.78
|
| Rate for Payer: Cigna Commercial |
$467.19
|
| Rate for Payer: First Health Commercial |
$494.67
|
| Rate for Payer: First Health Workers Compensation |
$212.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$494.67
|
| Rate for Payer: GEHA Commercial |
$439.70
|
| Rate for Payer: GEHA Medicare |
$681.76
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$494.67
|
| Rate for Payer: Humana ChoiceCare |
$749.94
|
| Rate for Payer: Humana Medicare Advantage |
$681.76
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,145.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$670.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$681.76
|
| Rate for Payer: Multiplan All |
$500.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,158.99
|
| Rate for Payer: OMNI Networks Commercial |
$384.74
|
| Rate for Payer: One Health Plan PPO/POS |
$494.67
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$774.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$670.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$681.76
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,363.52
|
| Rate for Payer: Three Rivers Provider Network All |
$412.22
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$668.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$670.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$681.76
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$681.76
|
| Rate for Payer: Zelis Auto |
$219.85
|
| Rate for Payer: Zelis Medicare |
$579.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$818.11
|
| Rate for Payer: Zelis Worker's Compensation |
$150.05
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
6111403
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$124.76 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: First Health Workers Compensation |
$176.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$319.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: Zelis Auto |
$182.80
|
| Rate for Payer: Zelis Worker's Compensation |
$124.76
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
20300109
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.25 |
| Max. Negotiated Rate |
$557.65 |
| Rate for Payer: Cash Price |
$352.20
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$528.30
|
| Rate for Payer: First Health Workers Compensation |
$226.64
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$528.30
|
| Rate for Payer: GEHA Commercial |
$410.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$528.30
|
| Rate for Payer: Multiplan All |
$534.17
|
| Rate for Payer: OMNI Networks Commercial |
$410.90
|
| Rate for Payer: One Health Plan PPO/POS |
$528.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$557.65
|
| Rate for Payer: Three Rivers Provider Network All |
$440.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$545.91
|
| Rate for Payer: Zelis Auto |
$234.80
|
| Rate for Payer: Zelis Worker's Compensation |
$160.25
|
|
|
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3 CM
|
Facility
|
IP
|
$4,816.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
1911403
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,314.77 |
| Max. Negotiated Rate |
$4,575.20 |
| Rate for Payer: Cash Price |
$2,889.60
|
| Rate for Payer: Cigna Commercial |
$4,093.60
|
| Rate for Payer: First Health Commercial |
$4,334.40
|
| Rate for Payer: First Health Workers Compensation |
$1,859.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,334.40
|
| Rate for Payer: GEHA Commercial |
$3,371.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,334.40
|
| Rate for Payer: Multiplan All |
$4,382.56
|
| Rate for Payer: OMNI Networks Commercial |
$3,371.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,334.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,575.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,612.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,478.88
|
| Rate for Payer: Zelis Auto |
$1,926.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,314.77
|
|
