|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 2.1-3
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
CPT 11423
|
| Hospital Charge Code |
6111423
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$131.59 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$289.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cigna Commercial |
$409.70
|
| Rate for Payer: First Health Commercial |
$433.80
|
| Rate for Payer: First Health Workers Compensation |
$186.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$433.80
|
| Rate for Payer: GEHA Commercial |
$385.60
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$433.80
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$438.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$337.40
|
| Rate for Payer: One Health Plan PPO/POS |
$433.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$457.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$361.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$448.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$192.80
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$131.59
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 2.1-3
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
CPT 11423
|
| Hospital Charge Code |
20311423
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$131.59 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$289.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cigna Commercial |
$409.70
|
| Rate for Payer: First Health Commercial |
$433.80
|
| Rate for Payer: First Health Workers Compensation |
$186.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$433.80
|
| Rate for Payer: GEHA Commercial |
$385.60
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$433.80
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$438.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$337.40
|
| Rate for Payer: One Health Plan PPO/POS |
$433.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$457.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$361.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$448.26
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$192.80
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$131.59
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 2.1-3
|
Facility
|
IP
|
$572.73
|
|
|
Service Code
|
CPT 11423
|
| Hospital Charge Code |
7211423
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$156.36 |
| Max. Negotiated Rate |
$544.09 |
| Rate for Payer: Cash Price |
$343.64
|
| Rate for Payer: Cigna Commercial |
$486.82
|
| Rate for Payer: First Health Commercial |
$515.46
|
| Rate for Payer: First Health Workers Compensation |
$221.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$515.46
|
| Rate for Payer: GEHA Commercial |
$400.91
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$515.46
|
| Rate for Payer: Multiplan All |
$521.18
|
| Rate for Payer: OMNI Networks Commercial |
$400.91
|
| Rate for Payer: One Health Plan PPO/POS |
$515.46
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$544.09
|
| Rate for Payer: Three Rivers Provider Network All |
$429.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$532.64
|
| Rate for Payer: Zelis Auto |
$229.09
|
| Rate for Payer: Zelis Worker's Compensation |
$156.36
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 2.1-3
|
Facility
|
IP
|
$482.00
|
|
|
Service Code
|
CPT 11423
|
| Hospital Charge Code |
20311423
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$131.59 |
| Max. Negotiated Rate |
$457.90 |
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cigna Commercial |
$409.70
|
| Rate for Payer: First Health Commercial |
$433.80
|
| Rate for Payer: First Health Workers Compensation |
$186.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$433.80
|
| Rate for Payer: GEHA Commercial |
$337.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$433.80
|
| Rate for Payer: Multiplan All |
$438.62
|
| Rate for Payer: OMNI Networks Commercial |
$337.40
|
| Rate for Payer: One Health Plan PPO/POS |
$433.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$457.90
|
| Rate for Payer: Three Rivers Provider Network All |
$361.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$448.26
|
| Rate for Payer: Zelis Auto |
$192.80
|
| Rate for Payer: Zelis Worker's Compensation |
$131.59
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
OP
|
$666.54
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
8511424
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$181.97 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$399.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cigna Commercial |
$566.56
|
| Rate for Payer: First Health Commercial |
$599.89
|
| Rate for Payer: First Health Workers Compensation |
$257.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$599.89
|
| Rate for Payer: GEHA Commercial |
$533.23
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$599.89
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$606.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$466.58
|
| Rate for Payer: One Health Plan PPO/POS |
$599.89
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$633.21
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$499.90
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$619.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$266.62
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$181.97
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
6111424
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$152.06 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$334.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$334.20
|
| Rate for Payer: Cash Price |
$334.20
|
| Rate for Payer: Cigna Commercial |
$473.45
|
| Rate for Payer: First Health Commercial |
$501.30
|
| Rate for Payer: First Health Workers Compensation |
$215.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$501.30
|
| Rate for Payer: GEHA Commercial |
$445.60
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$501.30
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$506.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$389.90
|
| Rate for Payer: One Health Plan PPO/POS |
$501.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$529.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$417.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$518.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$222.80
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$152.06
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
OP
|
$666.54
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
7211424
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$181.97 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$399.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cigna Commercial |
$566.56
|
| Rate for Payer: First Health Commercial |
$599.89
|
| Rate for Payer: First Health Workers Compensation |
$257.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$599.89
|
| Rate for Payer: GEHA Commercial |
$533.23
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$599.89
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$606.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$466.58
|
| Rate for Payer: One Health Plan PPO/POS |
$599.89
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$633.21
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$499.90
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$619.88
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$266.62
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$181.97
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
6111424
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$152.06 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Cash Price |
$334.20
|
| Rate for Payer: Cigna Commercial |
$473.45
|
| Rate for Payer: First Health Commercial |
$501.30
|
| Rate for Payer: First Health Workers Compensation |
$215.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$501.30
|
| Rate for Payer: GEHA Commercial |
$389.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$501.30
|
| Rate for Payer: Multiplan All |
$506.87
|
| Rate for Payer: OMNI Networks Commercial |
$389.90
|
| Rate for Payer: One Health Plan PPO/POS |
$501.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$529.15
|
| Rate for Payer: Three Rivers Provider Network All |
$417.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$518.01
|
| Rate for Payer: Zelis Auto |
$222.80
|
| Rate for Payer: Zelis Worker's Compensation |
$152.06
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
OP
|
$713.00
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
9400023
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$194.65 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$427.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$606.05
|
| Rate for Payer: First Health Commercial |
$641.70
|
| Rate for Payer: First Health Workers Compensation |
$275.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$641.70
|
| Rate for Payer: GEHA Commercial |
$570.40
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$641.70
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$648.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$499.10
|
| Rate for Payer: One Health Plan PPO/POS |
$641.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$677.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$534.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$663.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$285.20
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$194.65
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
IP
|
$666.54
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
7211424
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$181.97 |
| Max. Negotiated Rate |
$633.21 |
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cigna Commercial |
$566.56
|
| Rate for Payer: First Health Commercial |
$599.89
|
| Rate for Payer: First Health Workers Compensation |
$257.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$599.89
|
| Rate for Payer: GEHA Commercial |
$466.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$599.89
|
| Rate for Payer: Multiplan All |
$606.55
|
| Rate for Payer: OMNI Networks Commercial |
$466.58
|
| Rate for Payer: One Health Plan PPO/POS |
$599.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$633.21
|
| Rate for Payer: Three Rivers Provider Network All |
$499.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$619.88
|
| Rate for Payer: Zelis Auto |
$266.62
|
| Rate for Payer: Zelis Worker's Compensation |
$181.97
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
IP
|
$666.54
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
8511424
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$181.97 |
| Max. Negotiated Rate |
$633.21 |
| Rate for Payer: Cash Price |
$399.92
|
| Rate for Payer: Cigna Commercial |
$566.56
|
| Rate for Payer: First Health Commercial |
$599.89
|
| Rate for Payer: First Health Workers Compensation |
$257.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$599.89
|
| Rate for Payer: GEHA Commercial |
$466.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$599.89
|
| Rate for Payer: Multiplan All |
$606.55
|
| Rate for Payer: OMNI Networks Commercial |
$466.58
|
| Rate for Payer: One Health Plan PPO/POS |
$599.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$633.21
|
| Rate for Payer: Three Rivers Provider Network All |
$499.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$619.88
|
| Rate for Payer: Zelis Auto |
$266.62
|
| Rate for Payer: Zelis Worker's Compensation |
$181.97
|
|
|
EXC B9 LS MRGN XCP SK TG S/N/H/F/G 3.1-4
|
Facility
|
IP
|
$713.00
|
|
|
Service Code
|
CPT 11424
|
| Hospital Charge Code |
9400023
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$194.65 |
| Max. Negotiated Rate |
$677.35 |
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$606.05
|
| Rate for Payer: First Health Commercial |
$641.70
|
| Rate for Payer: First Health Workers Compensation |
$275.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$641.70
|
| Rate for Payer: GEHA Commercial |
$499.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$641.70
|
| Rate for Payer: Multiplan All |
$648.83
|
| Rate for Payer: OMNI Networks Commercial |
$499.10
|
| Rate for Payer: One Health Plan PPO/POS |
$641.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$677.35
|
| Rate for Payer: Three Rivers Provider Network All |
$534.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$663.09
|
| Rate for Payer: Zelis Auto |
$285.20
|
| Rate for Payer: Zelis Worker's Compensation |
$194.65
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
IP
|
$938.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
6121930
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$256.07 |
| Max. Negotiated Rate |
$891.10 |
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cigna Commercial |
$797.30
|
| Rate for Payer: First Health Commercial |
$844.20
|
| Rate for Payer: First Health Workers Compensation |
$362.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$844.20
|
| Rate for Payer: GEHA Commercial |
$656.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$844.20
|
| Rate for Payer: Multiplan All |
$853.58
|
| Rate for Payer: OMNI Networks Commercial |
$656.60
|
| Rate for Payer: One Health Plan PPO/POS |
$844.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$891.10
|
| Rate for Payer: Three Rivers Provider Network All |
$703.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$872.34
|
| Rate for Payer: Zelis Auto |
$375.20
|
| Rate for Payer: Zelis Worker's Compensation |
$256.07
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
OP
|
$938.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
6121930
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$256.07 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$562.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cigna Commercial |
$797.30
|
| Rate for Payer: First Health Commercial |
$844.20
|
| Rate for Payer: First Health Workers Compensation |
$362.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$844.20
|
| Rate for Payer: GEHA Commercial |
$750.40
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$844.20
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$853.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$656.60
|
| Rate for Payer: One Health Plan PPO/POS |
$844.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$891.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$703.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$872.34
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$375.20
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$256.07
|
|
|
EXC BACK LES SC 3 CM/>
|
Facility
|
OP
|
$974.00
|
|
|
Service Code
|
CPT 21931
|
| Hospital Charge Code |
6121931
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$265.90 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,364.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$584.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,364.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,873.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cigna Commercial |
$827.90
|
| Rate for Payer: First Health Commercial |
$876.60
|
| Rate for Payer: First Health Workers Compensation |
$376.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$876.60
|
| Rate for Payer: GEHA Commercial |
$779.20
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$876.60
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,911.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$886.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$681.80
|
| Rate for Payer: One Health Plan PPO/POS |
$876.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,207.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,911.49
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$925.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$730.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,911.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$905.82
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$389.60
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$265.90
|
|
|
EXC BACK LES SC 3 CM/>
|
Facility
|
IP
|
$974.00
|
|
|
Service Code
|
CPT 21931
|
| Hospital Charge Code |
6121931
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$265.90 |
| Max. Negotiated Rate |
$925.30 |
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cigna Commercial |
$827.90
|
| Rate for Payer: First Health Commercial |
$876.60
|
| Rate for Payer: First Health Workers Compensation |
$376.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$876.60
|
| Rate for Payer: GEHA Commercial |
$681.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$876.60
|
| Rate for Payer: Multiplan All |
$886.34
|
| Rate for Payer: OMNI Networks Commercial |
$681.80
|
| Rate for Payer: One Health Plan PPO/POS |
$876.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$925.30
|
| Rate for Payer: Three Rivers Provider Network All |
$730.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$905.82
|
| Rate for Payer: Zelis Auto |
$389.60
|
| Rate for Payer: Zelis Worker's Compensation |
$265.90
|
|
|
EXC BACK TUM DEEP < 5 CM
|
Facility
|
IP
|
$1,374.00
|
|
|
Service Code
|
CPT 21932
|
| Hospital Charge Code |
6121932
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$375.10 |
| Max. Negotiated Rate |
$1,305.30 |
| Rate for Payer: Cash Price |
$824.40
|
| Rate for Payer: Cigna Commercial |
$1,167.90
|
| Rate for Payer: First Health Commercial |
$1,236.60
|
| Rate for Payer: First Health Workers Compensation |
$530.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,236.60
|
| Rate for Payer: GEHA Commercial |
$961.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,236.60
|
| Rate for Payer: Multiplan All |
$1,250.34
|
| Rate for Payer: OMNI Networks Commercial |
$961.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,236.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,305.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,030.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,277.82
|
| Rate for Payer: Zelis Auto |
$549.60
|
| Rate for Payer: Zelis Worker's Compensation |
$375.10
|
|
|
EXC BACK TUM DEEP < 5 CM
|
Facility
|
OP
|
$1,374.00
|
|
|
Service Code
|
CPT 21932
|
| Hospital Charge Code |
6121932
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$375.10 |
| Max. Negotiated Rate |
$5,435.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$824.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,717.63
|
| Rate for Payer: Cash Price |
$824.40
|
| Rate for Payer: Cash Price |
$824.40
|
| Rate for Payer: Cigna Commercial |
$1,167.90
|
| Rate for Payer: First Health Commercial |
$1,236.60
|
| Rate for Payer: First Health Workers Compensation |
$530.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,236.60
|
| Rate for Payer: GEHA Commercial |
$1,099.20
|
| Rate for Payer: GEHA Medicare |
$2,717.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,236.60
|
| Rate for Payer: Humana ChoiceCare |
$2,989.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,717.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,565.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,717.63
|
| Rate for Payer: Multiplan All |
$1,250.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,619.97
|
| Rate for Payer: OMNI Networks Commercial |
$961.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,236.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,717.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,305.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,435.26
|
| Rate for Payer: Three Rivers Provider Network All |
$1,030.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,663.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,717.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,277.82
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,717.63
|
| Rate for Payer: Zelis Auto |
$549.60
|
| Rate for Payer: Zelis Medicare |
$2,309.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,261.16
|
| Rate for Payer: Zelis Worker's Compensation |
$375.10
|
|
|
EXC BACK TUM DEEP 5 CM/>
|
Facility
|
OP
|
$1,532.00
|
|
|
Service Code
|
CPT 21933
|
| Hospital Charge Code |
6121933
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$418.24 |
| Max. Negotiated Rate |
$5,435.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,364.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$919.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,364.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,873.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$2,717.63
|
| Rate for Payer: Cash Price |
$919.20
|
| Rate for Payer: Cash Price |
$919.20
|
| Rate for Payer: Cigna Commercial |
$1,302.20
|
| Rate for Payer: First Health Commercial |
$1,378.80
|
| Rate for Payer: First Health Workers Compensation |
$591.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,378.80
|
| Rate for Payer: GEHA Commercial |
$1,225.60
|
| Rate for Payer: GEHA Medicare |
$2,717.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,378.80
|
| Rate for Payer: Humana ChoiceCare |
$2,989.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,717.63
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$4,565.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,911.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$2,717.63
|
| Rate for Payer: Multiplan All |
$1,394.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,619.97
|
| Rate for Payer: OMNI Networks Commercial |
$1,072.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,378.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,207.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,911.49
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$2,717.63
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,455.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$5,435.26
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,663.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,911.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,717.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,424.76
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$2,717.63
|
| Rate for Payer: Zelis Auto |
$612.80
|
| Rate for Payer: Zelis Medicare |
$2,309.99
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,261.16
|
| Rate for Payer: Zelis Worker's Compensation |
$418.24
|
|
|
EXC BACK TUM DEEP 5 CM/>
|
Facility
|
IP
|
$1,532.00
|
|
|
Service Code
|
CPT 21933
|
| Hospital Charge Code |
6121933
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$418.24 |
| Max. Negotiated Rate |
$1,455.40 |
| Rate for Payer: Cash Price |
$919.20
|
| Rate for Payer: Cigna Commercial |
$1,302.20
|
| Rate for Payer: First Health Commercial |
$1,378.80
|
| Rate for Payer: First Health Workers Compensation |
$591.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,378.80
|
| Rate for Payer: GEHA Commercial |
$1,072.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,378.80
|
| Rate for Payer: Multiplan All |
$1,394.12
|
| Rate for Payer: OMNI Networks Commercial |
$1,072.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,378.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,455.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,424.76
|
| Rate for Payer: Zelis Auto |
$612.80
|
| Rate for Payer: Zelis Worker's Compensation |
$418.24
|
|
|
EXC CYST/ABRRNT BREAST TISS OPEN 1/> LES
|
Facility
|
OP
|
$1,546.00
|
|
|
Service Code
|
CPT 19120
|
| Hospital Charge Code |
20300058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$422.06 |
| Max. Negotiated Rate |
$7,272.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,502.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$927.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,502.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,982.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,636.05
|
| Rate for Payer: Cash Price |
$927.60
|
| Rate for Payer: Cash Price |
$927.60
|
| Rate for Payer: Cigna Commercial |
$1,314.10
|
| Rate for Payer: First Health Commercial |
$1,391.40
|
| Rate for Payer: First Health Workers Compensation |
$596.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,391.40
|
| Rate for Payer: GEHA Commercial |
$1,236.80
|
| Rate for Payer: GEHA Medicare |
$3,636.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,391.40
|
| Rate for Payer: Humana ChoiceCare |
$3,999.66
|
| Rate for Payer: Humana Medicare Advantage |
$3,636.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6,108.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,022.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,636.05
|
| Rate for Payer: Multiplan All |
$1,406.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,181.28
|
| Rate for Payer: OMNI Networks Commercial |
$1,082.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,391.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,335.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,022.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,636.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,468.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7,272.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,159.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,563.33
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,022.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,636.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,437.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,636.05
|
| Rate for Payer: Zelis Auto |
$618.40
|
| Rate for Payer: Zelis Medicare |
$3,090.64
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,363.26
|
| Rate for Payer: Zelis Worker's Compensation |
$422.06
|
|
|
EXC CYST/ABRRNT BREAST TISS OPEN 1/> LES
|
Facility
|
OP
|
$1,519.47
|
|
|
Service Code
|
CPT 19120
|
| Hospital Charge Code |
6119120
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$414.82 |
| Max. Negotiated Rate |
$7,272.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,502.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$911.68
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,502.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,982.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,636.05
|
| Rate for Payer: Cash Price |
$911.68
|
| Rate for Payer: Cash Price |
$911.68
|
| Rate for Payer: Cigna Commercial |
$1,291.55
|
| Rate for Payer: First Health Commercial |
$1,367.52
|
| Rate for Payer: First Health Workers Compensation |
$586.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,367.52
|
| Rate for Payer: GEHA Commercial |
$1,215.58
|
| Rate for Payer: GEHA Medicare |
$3,636.05
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,367.52
|
| Rate for Payer: Humana ChoiceCare |
$3,999.66
|
| Rate for Payer: Humana Medicare Advantage |
$3,636.05
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$6,108.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,022.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,636.05
|
| Rate for Payer: Multiplan All |
$1,382.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,181.28
|
| Rate for Payer: OMNI Networks Commercial |
$1,063.63
|
| Rate for Payer: One Health Plan PPO/POS |
$1,367.52
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,335.77
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,022.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,636.05
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,443.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$7,272.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,139.60
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,563.33
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,022.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,636.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,413.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,636.05
|
| Rate for Payer: Zelis Auto |
$607.79
|
| Rate for Payer: Zelis Medicare |
$3,090.64
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,363.26
|
| Rate for Payer: Zelis Worker's Compensation |
$414.82
|
|
|
EXC CYST/ABRRNT BREAST TISS OPEN 1/> LES
|
Facility
|
IP
|
$1,546.00
|
|
|
Service Code
|
CPT 19120
|
| Hospital Charge Code |
20300058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$422.06 |
| Max. Negotiated Rate |
$1,468.70 |
| Rate for Payer: Cash Price |
$927.60
|
| Rate for Payer: Cigna Commercial |
$1,314.10
|
| Rate for Payer: First Health Commercial |
$1,391.40
|
| Rate for Payer: First Health Workers Compensation |
$596.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,391.40
|
| Rate for Payer: GEHA Commercial |
$1,082.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,391.40
|
| Rate for Payer: Multiplan All |
$1,406.86
|
| Rate for Payer: OMNI Networks Commercial |
$1,082.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,391.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,468.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,159.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,437.78
|
| Rate for Payer: Zelis Auto |
$618.40
|
| Rate for Payer: Zelis Worker's Compensation |
$422.06
|
|
|
EXC CYST/ABRRNT BREAST TISS OPEN 1/> LES
|
Facility
|
IP
|
$1,519.47
|
|
|
Service Code
|
CPT 19120
|
| Hospital Charge Code |
6119120
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$414.82 |
| Max. Negotiated Rate |
$1,443.50 |
| Rate for Payer: Cash Price |
$911.68
|
| Rate for Payer: Cigna Commercial |
$1,291.55
|
| Rate for Payer: First Health Commercial |
$1,367.52
|
| Rate for Payer: First Health Workers Compensation |
$586.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,367.52
|
| Rate for Payer: GEHA Commercial |
$1,063.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,367.52
|
| Rate for Payer: Multiplan All |
$1,382.72
|
| Rate for Payer: OMNI Networks Commercial |
$1,063.63
|
| Rate for Payer: One Health Plan PPO/POS |
$1,367.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,443.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,139.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,413.11
|
| Rate for Payer: Zelis Auto |
$607.79
|
| Rate for Payer: Zelis Worker's Compensation |
$414.82
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
OP
|
$657.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
6121011
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$179.36 |
| Max. Negotiated Rate |
$3,076.96 |
| 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 |
$394.20
|
| 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 |
$1,538.48
|
| Rate for Payer: Cash Price |
$394.20
|
| Rate for Payer: Cash Price |
$394.20
|
| Rate for Payer: Cigna Commercial |
$558.45
|
| Rate for Payer: First Health Commercial |
$591.30
|
| Rate for Payer: First Health Workers Compensation |
$253.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$591.30
|
| Rate for Payer: GEHA Commercial |
$525.60
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$591.30
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$670.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$597.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$459.90
|
| Rate for Payer: One Health Plan PPO/POS |
$591.30
|
| 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 |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$624.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$492.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$670.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$611.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$262.80
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$179.36
|
|
