|
EXPLORE WOUND CHEST
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
CPT 20101
|
| Hospital Charge Code |
6120101
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$148.51 |
| Max. Negotiated Rate |
$516.80 |
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cigna Commercial |
$462.40
|
| Rate for Payer: First Health Commercial |
$489.60
|
| Rate for Payer: First Health Workers Compensation |
$210.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$489.60
|
| Rate for Payer: GEHA Commercial |
$380.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$489.60
|
| Rate for Payer: Multiplan All |
$495.04
|
| Rate for Payer: OMNI Networks Commercial |
$380.80
|
| Rate for Payer: One Health Plan PPO/POS |
$489.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$516.80
|
| Rate for Payer: Three Rivers Provider Network All |
$408.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$505.92
|
| Rate for Payer: Zelis Auto |
$217.60
|
| Rate for Payer: Zelis Worker's Compensation |
$148.51
|
|
|
EXPLORE WOUND EXTREMITY
|
Facility
|
OP
|
$1,555.32
|
|
|
Service Code
|
CPT 20103
|
| Hospital Charge Code |
6120103
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$424.60 |
| Max. Negotiated Rate |
$3,139.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,276.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$933.19
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,276.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,010.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,569.98
|
| Rate for Payer: Cash Price |
$933.19
|
| Rate for Payer: Cash Price |
$933.19
|
| Rate for Payer: Cigna Commercial |
$1,322.02
|
| Rate for Payer: First Health Commercial |
$1,399.79
|
| Rate for Payer: First Health Workers Compensation |
$600.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,399.79
|
| Rate for Payer: GEHA Commercial |
$1,244.26
|
| Rate for Payer: GEHA Medicare |
$1,569.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,399.79
|
| Rate for Payer: Humana ChoiceCare |
$1,726.98
|
| Rate for Payer: Humana Medicare Advantage |
$1,569.98
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,637.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,031.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,569.98
|
| Rate for Payer: Multiplan All |
$1,415.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,668.97
|
| Rate for Payer: OMNI Networks Commercial |
$1,088.72
|
| Rate for Payer: One Health Plan PPO/POS |
$1,399.79
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,191.09
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,031.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,569.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,477.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,139.96
|
| Rate for Payer: Three Rivers Provider Network All |
$1,166.49
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,538.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,031.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,569.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,446.45
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,569.98
|
| Rate for Payer: Zelis Auto |
$622.13
|
| Rate for Payer: Zelis Medicare |
$1,334.48
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,883.98
|
| Rate for Payer: Zelis Worker's Compensation |
$424.60
|
|
|
EXPLORE WOUND EXTREMITY
|
Facility
|
IP
|
$1,555.32
|
|
|
Service Code
|
CPT 20103
|
| Hospital Charge Code |
6120103
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$424.60 |
| Max. Negotiated Rate |
$1,477.55 |
| Rate for Payer: Cash Price |
$933.19
|
| Rate for Payer: Cigna Commercial |
$1,322.02
|
| Rate for Payer: First Health Commercial |
$1,399.79
|
| Rate for Payer: First Health Workers Compensation |
$600.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,399.79
|
| Rate for Payer: GEHA Commercial |
$1,088.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,399.79
|
| Rate for Payer: Multiplan All |
$1,415.34
|
| Rate for Payer: OMNI Networks Commercial |
$1,088.72
|
| Rate for Payer: One Health Plan PPO/POS |
$1,399.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,477.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,166.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,446.45
|
| Rate for Payer: Zelis Auto |
$622.13
|
| Rate for Payer: Zelis Worker's Compensation |
$424.60
|
|
|
EXPLORE WOUND NECK
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
CPT 20100
|
| Hospital Charge Code |
6120100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$347.26 |
| Max. Negotiated Rate |
$1,208.40 |
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cigna Commercial |
$1,081.20
|
| Rate for Payer: First Health Commercial |
$1,144.80
|
| Rate for Payer: First Health Workers Compensation |
$491.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,144.80
|
| Rate for Payer: GEHA Commercial |
$890.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,144.80
|
| Rate for Payer: Multiplan All |
$1,157.52
|
| Rate for Payer: OMNI Networks Commercial |
$890.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,144.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,208.40
|
| Rate for Payer: Three Rivers Provider Network All |
$954.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,182.96
|
| Rate for Payer: Zelis Auto |
$508.80
|
| Rate for Payer: Zelis Worker's Compensation |
$347.26
|
|
|
EXPLORE WOUND NECK
|
Facility
|
OP
|
$1,272.00
|
|
|
Service Code
|
CPT 20100
|
| Hospital Charge Code |
6120100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$347.26 |
| Max. Negotiated Rate |
$1,208.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$763.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$493.45
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cigna Commercial |
$1,081.20
|
| Rate for Payer: First Health Commercial |
$1,144.80
|
| Rate for Payer: First Health Workers Compensation |
$491.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,144.80
|
| Rate for Payer: GEHA Commercial |
$1,017.60
|
| Rate for Payer: GEHA Medicare |
$493.45
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,144.80
|
| Rate for Payer: Humana ChoiceCare |
$542.79
|
| Rate for Payer: Humana Medicare Advantage |
$493.45
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$829.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$622.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$493.45
|
| Rate for Payer: Multiplan All |
$1,157.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$838.87
|
| Rate for Payer: OMNI Networks Commercial |
$890.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,144.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$719.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$622.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$493.45
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,208.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$986.90
|
| Rate for Payer: Three Rivers Provider Network All |
$954.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$483.58
|
| Rate for Payer: United Healthcare Managed Medicaid |
$622.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$493.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,182.96
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$493.45
|
| Rate for Payer: Zelis Auto |
$508.80
|
| Rate for Payer: Zelis Medicare |
$419.43
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$592.14
|
| Rate for Payer: Zelis Worker's Compensation |
$347.26
|
|
|
EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD
|
Facility
|
OP
|
$3,605.94
|
|
|
Service Code
|
CPT 35840
|
| Hospital Charge Code |
6135840
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$901.49 |
| Max. Negotiated Rate |
$3,425.64 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,163.56
|
| Rate for Payer: Cash Price |
$2,163.56
|
| Rate for Payer: Cigna Commercial |
$3,065.05
|
| Rate for Payer: First Health Commercial |
$3,245.35
|
| Rate for Payer: First Health Workers Compensation |
$1,392.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,245.35
|
| Rate for Payer: GEHA Commercial |
$2,884.75
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,245.35
|
| Rate for Payer: Humana ChoiceCare |
$937.54
|
| Rate for Payer: Multiplan All |
$3,281.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,163.56
|
| Rate for Payer: OMNI Networks Commercial |
$2,524.16
|
| Rate for Payer: One Health Plan PPO/POS |
$3,245.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,425.64
|
| Rate for Payer: Three Rivers Provider Network All |
$2,704.45
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,173.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$901.49
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,353.52
|
| Rate for Payer: Zelis Auto |
$1,442.38
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,802.97
|
| Rate for Payer: Zelis Worker's Compensation |
$984.42
|
|
|
EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD
|
Facility
|
IP
|
$3,605.94
|
|
|
Service Code
|
CPT 35840
|
| Hospital Charge Code |
6135840
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$984.42 |
| Max. Negotiated Rate |
$3,425.64 |
| Rate for Payer: Cash Price |
$2,163.56
|
| Rate for Payer: Cigna Commercial |
$3,065.05
|
| Rate for Payer: First Health Commercial |
$3,245.35
|
| Rate for Payer: First Health Workers Compensation |
$1,392.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,245.35
|
| Rate for Payer: GEHA Commercial |
$2,524.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,245.35
|
| Rate for Payer: Multiplan All |
$3,281.41
|
| Rate for Payer: OMNI Networks Commercial |
$2,524.16
|
| Rate for Payer: One Health Plan PPO/POS |
$3,245.35
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,425.64
|
| Rate for Payer: Three Rivers Provider Network All |
$2,704.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,353.52
|
| Rate for Payer: Zelis Auto |
$1,442.38
|
| Rate for Payer: Zelis Worker's Compensation |
$984.42
|
|
|
EXPL W/REMVL DP FOREIGN BODY FOREARM/WRI
|
Facility
|
OP
|
$847.00
|
|
|
Service Code
|
CPT 25248
|
| Hospital Charge Code |
6125248
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$231.23 |
| Max. Negotiated Rate |
$3,101.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$508.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,550.77
|
| Rate for Payer: Cash Price |
$508.20
|
| Rate for Payer: Cash Price |
$508.20
|
| Rate for Payer: Cigna Commercial |
$719.95
|
| Rate for Payer: First Health Commercial |
$762.30
|
| Rate for Payer: First Health Workers Compensation |
$327.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$762.30
|
| Rate for Payer: GEHA Commercial |
$677.60
|
| Rate for Payer: GEHA Medicare |
$1,550.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$762.30
|
| Rate for Payer: Humana ChoiceCare |
$1,705.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,550.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,605.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,550.77
|
| Rate for Payer: Multiplan All |
$770.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,636.31
|
| Rate for Payer: OMNI Networks Commercial |
$592.90
|
| Rate for Payer: One Health Plan PPO/POS |
$762.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,550.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$804.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,101.54
|
| Rate for Payer: Three Rivers Provider Network All |
$635.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,519.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,550.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$787.71
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,550.77
|
| Rate for Payer: Zelis Auto |
$338.80
|
| Rate for Payer: Zelis Medicare |
$1,318.15
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,860.92
|
| Rate for Payer: Zelis Worker's Compensation |
$231.23
|
|
|
EXPL W/REMVL DP FOREIGN BODY FOREARM/WRI
|
Facility
|
OP
|
$1,285.00
|
|
|
Service Code
|
CPT 25248
|
| Hospital Charge Code |
21600470
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$350.81 |
| Max. Negotiated Rate |
$3,101.54 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$771.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,225.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,763.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,550.77
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,092.25
|
| Rate for Payer: First Health Commercial |
$1,156.50
|
| Rate for Payer: First Health Workers Compensation |
$496.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,156.50
|
| Rate for Payer: GEHA Commercial |
$1,028.00
|
| Rate for Payer: GEHA Medicare |
$1,550.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,156.50
|
| Rate for Payer: Humana ChoiceCare |
$1,705.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,550.77
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,605.29
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,799.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,550.77
|
| Rate for Payer: Multiplan All |
$1,169.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,636.31
|
| Rate for Payer: OMNI Networks Commercial |
$899.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,156.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,077.52
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,799.28
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,550.77
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,220.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,101.54
|
| Rate for Payer: Three Rivers Provider Network All |
$963.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,519.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,799.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,550.77
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,195.05
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,550.77
|
| Rate for Payer: Zelis Auto |
$514.00
|
| Rate for Payer: Zelis Medicare |
$1,318.15
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,860.92
|
| Rate for Payer: Zelis Worker's Compensation |
$350.81
|
|
|
EXPL W/REMVL DP FOREIGN BODY FOREARM/WRI
|
Facility
|
IP
|
$1,285.00
|
|
|
Service Code
|
CPT 25248
|
| Hospital Charge Code |
21600470
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$350.81 |
| Max. Negotiated Rate |
$1,220.75 |
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,092.25
|
| Rate for Payer: First Health Commercial |
$1,156.50
|
| Rate for Payer: First Health Workers Compensation |
$496.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,156.50
|
| Rate for Payer: GEHA Commercial |
$899.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,156.50
|
| Rate for Payer: Multiplan All |
$1,169.35
|
| Rate for Payer: OMNI Networks Commercial |
$899.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,156.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,220.75
|
| Rate for Payer: Three Rivers Provider Network All |
$963.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,195.05
|
| Rate for Payer: Zelis Auto |
$514.00
|
| Rate for Payer: Zelis Worker's Compensation |
$350.81
|
|
|
EXPL W/REMVL DP FOREIGN BODY FOREARM/WRI
|
Facility
|
IP
|
$847.00
|
|
|
Service Code
|
CPT 25248
|
| Hospital Charge Code |
6125248
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$231.23 |
| Max. Negotiated Rate |
$804.65 |
| Rate for Payer: Cash Price |
$508.20
|
| Rate for Payer: Cigna Commercial |
$719.95
|
| Rate for Payer: First Health Commercial |
$762.30
|
| Rate for Payer: First Health Workers Compensation |
$327.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$762.30
|
| Rate for Payer: GEHA Commercial |
$592.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$762.30
|
| Rate for Payer: Multiplan All |
$770.77
|
| Rate for Payer: OMNI Networks Commercial |
$592.90
|
| Rate for Payer: One Health Plan PPO/POS |
$762.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$804.65
|
| Rate for Payer: Three Rivers Provider Network All |
$635.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$787.71
|
| Rate for Payer: Zelis Auto |
$338.80
|
| Rate for Payer: Zelis Worker's Compensation |
$231.23
|
|
|
EXT DWELL CATHER DEVICE 20GA X 8CM
|
Facility
|
IP
|
$369.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7007000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.60 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$295.20
|
| Rate for Payer: Cash Price |
$221.40
|
| Rate for Payer: Cash Price |
$221.40
|
| Rate for Payer: Cigna Commercial |
$313.65
|
| Rate for Payer: First Health Commercial |
$332.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$332.10
|
| Rate for Payer: GEHA Commercial |
$258.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$332.10
|
| Rate for Payer: Multiplan All |
$335.79
|
| Rate for Payer: OMNI Networks Commercial |
$258.30
|
| Rate for Payer: One Health Plan PPO/POS |
$332.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$350.55
|
| Rate for Payer: Three Rivers Provider Network All |
$276.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$343.17
|
| Rate for Payer: Zelis Auto |
$147.60
|
|
|
EXT DWELL CATHER DEVICE 20GA X 8CM
|
Facility
|
OP
|
$369.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7007000
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$221.40
|
| Rate for Payer: Cash Price |
$221.40
|
| Rate for Payer: Cash Price |
$221.40
|
| Rate for Payer: Cigna Commercial |
$313.65
|
| Rate for Payer: First Health Commercial |
$332.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$332.10
|
| Rate for Payer: GEHA Commercial |
$295.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$332.10
|
| Rate for Payer: Humana ChoiceCare |
$95.94
|
| Rate for Payer: Multiplan All |
$335.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$221.40
|
| Rate for Payer: OMNI Networks Commercial |
$258.30
|
| Rate for Payer: One Health Plan PPO/POS |
$332.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$350.55
|
| Rate for Payer: Three Rivers Provider Network All |
$276.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$324.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$92.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$343.17
|
| Rate for Payer: Zelis Auto |
$147.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$184.50
|
|
|
EXT ECG>48HR<7D RECORDING ONLY
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
4093242
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$50.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$360.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$50.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$40.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$38.03
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$510.00
|
| Rate for Payer: First Health Commercial |
$540.00
|
| Rate for Payer: First Health Workers Compensation |
$231.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$540.00
|
| Rate for Payer: GEHA Commercial |
$480.00
|
| Rate for Payer: GEHA Medicare |
$38.03
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$540.00
|
| Rate for Payer: Humana ChoiceCare |
$41.83
|
| Rate for Payer: Humana Medicare Advantage |
$38.03
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$63.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$41.03
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$38.03
|
| Rate for Payer: Multiplan All |
$546.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.65
|
| Rate for Payer: OMNI Networks Commercial |
$420.00
|
| Rate for Payer: One Health Plan PPO/POS |
$540.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$47.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$41.03
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$38.03
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$570.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$76.06
|
| Rate for Payer: Three Rivers Provider Network All |
$450.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.27
|
| Rate for Payer: United Healthcare Commercial |
$510.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.03
|
| Rate for Payer: United Payors & United Providers UP&UP |
$558.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$38.03
|
| Rate for Payer: Zelis Auto |
$240.00
|
| Rate for Payer: Zelis Medicare |
$32.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.64
|
| Rate for Payer: Zelis Worker's Compensation |
$163.80
|
|
|
EXT ECG>48HR<7D RECORDING ONLY
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
4093242
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$510.00
|
| Rate for Payer: First Health Commercial |
$540.00
|
| Rate for Payer: First Health Workers Compensation |
$231.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$540.00
|
| Rate for Payer: GEHA Commercial |
$420.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$540.00
|
| Rate for Payer: Multiplan All |
$546.00
|
| Rate for Payer: OMNI Networks Commercial |
$420.00
|
| Rate for Payer: One Health Plan PPO/POS |
$540.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$570.00
|
| Rate for Payer: Three Rivers Provider Network All |
$450.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$558.00
|
| Rate for Payer: Zelis Auto |
$240.00
|
| Rate for Payer: Zelis Worker's Compensation |
$163.80
|
|
|
EXT ECG > 48HR TO 21 DAY RCRD SCAN ANLYS
|
Facility
|
OP
|
$927.00
|
|
|
Service Code
|
CPT 0295T
|
| Hospital Charge Code |
8600295
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$231.75 |
| Max. Negotiated Rate |
$880.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$556.20
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cigna Commercial |
$787.95
|
| Rate for Payer: First Health Commercial |
$834.30
|
| Rate for Payer: First Health Workers Compensation |
$357.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$834.30
|
| Rate for Payer: GEHA Commercial |
$741.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$834.30
|
| Rate for Payer: Humana ChoiceCare |
$241.02
|
| Rate for Payer: Multiplan All |
$843.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$556.20
|
| Rate for Payer: OMNI Networks Commercial |
$648.90
|
| Rate for Payer: One Health Plan PPO/POS |
$834.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$880.65
|
| Rate for Payer: Three Rivers Provider Network All |
$695.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$815.76
|
| Rate for Payer: United Healthcare Commercial |
$787.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$231.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$862.11
|
| Rate for Payer: Zelis Auto |
$370.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$463.50
|
| Rate for Payer: Zelis Worker's Compensation |
$253.07
|
|
|
EXT ECG > 48HR TO 21 DAY RCRD SCAN ANLYS
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
CPT 0295T
|
| Hospital Charge Code |
8600295
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$253.07 |
| Max. Negotiated Rate |
$880.65 |
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cigna Commercial |
$787.95
|
| Rate for Payer: First Health Commercial |
$834.30
|
| Rate for Payer: First Health Workers Compensation |
$357.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$834.30
|
| Rate for Payer: GEHA Commercial |
$648.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$834.30
|
| Rate for Payer: Multiplan All |
$843.57
|
| Rate for Payer: OMNI Networks Commercial |
$648.90
|
| Rate for Payer: One Health Plan PPO/POS |
$834.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$880.65
|
| Rate for Payer: Three Rivers Provider Network All |
$695.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$862.11
|
| Rate for Payer: Zelis Auto |
$370.80
|
| Rate for Payer: Zelis Worker's Compensation |
$253.07
|
|
|
EXT ECG>7D<15D RECORDING ONLY
|
Facility
|
OP
|
$670.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
4093246
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$636.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$83.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$402.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$83.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$66.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$38.03
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$569.50
|
| Rate for Payer: First Health Commercial |
$603.00
|
| Rate for Payer: First Health Workers Compensation |
$258.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$603.00
|
| Rate for Payer: GEHA Commercial |
$536.00
|
| Rate for Payer: GEHA Medicare |
$38.03
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$603.00
|
| Rate for Payer: Humana ChoiceCare |
$41.83
|
| Rate for Payer: Humana Medicare Advantage |
$38.03
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$63.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$67.49
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$38.03
|
| Rate for Payer: Multiplan All |
$609.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.65
|
| Rate for Payer: OMNI Networks Commercial |
$469.00
|
| Rate for Payer: One Health Plan PPO/POS |
$603.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$77.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$67.49
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$38.03
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$636.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$76.06
|
| Rate for Payer: Three Rivers Provider Network All |
$502.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$37.27
|
| Rate for Payer: United Healthcare Commercial |
$569.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$67.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.03
|
| Rate for Payer: United Payors & United Providers UP&UP |
$623.10
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$38.03
|
| Rate for Payer: Zelis Auto |
$268.00
|
| Rate for Payer: Zelis Medicare |
$32.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.64
|
| Rate for Payer: Zelis Worker's Compensation |
$182.91
|
|
|
EXT ECG>7D<15D RECORDING ONLY
|
Facility
|
IP
|
$670.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
4093246
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$182.91 |
| Max. Negotiated Rate |
$636.50 |
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$569.50
|
| Rate for Payer: First Health Commercial |
$603.00
|
| Rate for Payer: First Health Workers Compensation |
$258.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$603.00
|
| Rate for Payer: GEHA Commercial |
$469.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$603.00
|
| Rate for Payer: Multiplan All |
$609.70
|
| Rate for Payer: OMNI Networks Commercial |
$469.00
|
| Rate for Payer: One Health Plan PPO/POS |
$603.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$636.50
|
| Rate for Payer: Three Rivers Provider Network All |
$502.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$623.10
|
| Rate for Payer: Zelis Auto |
$268.00
|
| Rate for Payer: Zelis Worker's Compensation |
$182.91
|
|
|
EXT ECG REC>48HR<7D SCAN ALYS REPORT R&I
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
CPT 93241
|
| Hospital Charge Code |
8693241
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$325.42 |
| Max. Negotiated Rate |
$1,132.40 |
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$1,013.20
|
| Rate for Payer: First Health Commercial |
$1,072.80
|
| Rate for Payer: First Health Workers Compensation |
$460.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,072.80
|
| Rate for Payer: GEHA Commercial |
$834.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,072.80
|
| Rate for Payer: Multiplan All |
$1,084.72
|
| Rate for Payer: OMNI Networks Commercial |
$834.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,072.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,132.40
|
| Rate for Payer: Three Rivers Provider Network All |
$894.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,108.56
|
| Rate for Payer: Zelis Auto |
$476.80
|
| Rate for Payer: Zelis Worker's Compensation |
$325.42
|
|
|
EXT ECG REC>48HR<7D SCAN ALYS REPORT R&I
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
CPT 93241
|
| Hospital Charge Code |
8693241
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$298.00 |
| Max. Negotiated Rate |
$1,132.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$715.20
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$1,013.20
|
| Rate for Payer: First Health Commercial |
$1,072.80
|
| Rate for Payer: First Health Workers Compensation |
$460.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,072.80
|
| Rate for Payer: GEHA Commercial |
$953.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,072.80
|
| Rate for Payer: Humana ChoiceCare |
$309.92
|
| Rate for Payer: Multiplan All |
$1,084.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$715.20
|
| Rate for Payer: OMNI Networks Commercial |
$834.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,072.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,132.40
|
| Rate for Payer: Three Rivers Provider Network All |
$894.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,048.96
|
| Rate for Payer: United Healthcare Commercial |
$1,013.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,108.56
|
| Rate for Payer: Zelis Auto |
$476.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$596.00
|
| Rate for Payer: Zelis Worker's Compensation |
$325.42
|
|
|
EXTENSIVE HAND SURGERY
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 26250
|
| Hospital Charge Code |
6126250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$601.15 |
| Max. Negotiated Rate |
$6,287.92 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,321.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,143.96
|
| Rate for Payer: Cash Price |
$1,321.20
|
| Rate for Payer: Cash Price |
$1,321.20
|
| Rate for Payer: Cigna Commercial |
$1,871.70
|
| Rate for Payer: First Health Commercial |
$1,981.80
|
| Rate for Payer: First Health Workers Compensation |
$850.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,981.80
|
| Rate for Payer: GEHA Commercial |
$1,761.60
|
| Rate for Payer: GEHA Medicare |
$3,143.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,981.80
|
| Rate for Payer: Humana ChoiceCare |
$3,458.36
|
| Rate for Payer: Humana Medicare Advantage |
$3,143.96
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,281.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,143.96
|
| Rate for Payer: Multiplan All |
$2,003.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,344.73
|
| Rate for Payer: OMNI Networks Commercial |
$1,541.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,981.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,143.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,091.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,287.92
|
| Rate for Payer: Three Rivers Provider Network All |
$1,651.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,081.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,143.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,047.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,143.96
|
| Rate for Payer: Zelis Auto |
$880.80
|
| Rate for Payer: Zelis Medicare |
$2,672.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,772.75
|
| Rate for Payer: Zelis Worker's Compensation |
$601.15
|
|
|
EXTENSIVE HAND SURGERY
|
Facility
|
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 26250
|
| Hospital Charge Code |
6126250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$601.15 |
| Max. Negotiated Rate |
$2,091.90 |
| Rate for Payer: Cash Price |
$1,321.20
|
| Rate for Payer: Cigna Commercial |
$1,871.70
|
| Rate for Payer: First Health Commercial |
$1,981.80
|
| Rate for Payer: First Health Workers Compensation |
$850.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,981.80
|
| Rate for Payer: GEHA Commercial |
$1,541.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,981.80
|
| Rate for Payer: Multiplan All |
$2,003.82
|
| Rate for Payer: OMNI Networks Commercial |
$1,541.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,981.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,091.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,651.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,047.86
|
| Rate for Payer: Zelis Auto |
$880.80
|
| Rate for Payer: Zelis Worker's Compensation |
$601.15
|
|
|
EXTENSIVE JAW SURGERY
|
Facility
|
OP
|
$2,535.00
|
|
|
Service Code
|
CPT 21045
|
| Hospital Charge Code |
6121045
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$633.75 |
| Max. Negotiated Rate |
$2,408.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,521.00
|
| Rate for Payer: Cash Price |
$1,521.00
|
| Rate for Payer: Cigna Commercial |
$2,154.75
|
| Rate for Payer: First Health Commercial |
$2,281.50
|
| Rate for Payer: First Health Workers Compensation |
$978.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,281.50
|
| Rate for Payer: GEHA Commercial |
$2,028.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,281.50
|
| Rate for Payer: Humana ChoiceCare |
$659.10
|
| Rate for Payer: Multiplan All |
$2,306.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,521.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,774.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,281.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,408.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,901.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,230.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$633.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,357.55
|
| Rate for Payer: Zelis Auto |
$1,014.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,267.50
|
| Rate for Payer: Zelis Worker's Compensation |
$692.05
|
|
|
EXTENSIVE JAW SURGERY
|
Facility
|
IP
|
$2,535.00
|
|
|
Service Code
|
CPT 21045
|
| Hospital Charge Code |
6121045
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$692.05 |
| Max. Negotiated Rate |
$2,408.25 |
| Rate for Payer: Cash Price |
$1,521.00
|
| Rate for Payer: Cigna Commercial |
$2,154.75
|
| Rate for Payer: First Health Commercial |
$2,281.50
|
| Rate for Payer: First Health Workers Compensation |
$978.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,281.50
|
| Rate for Payer: GEHA Commercial |
$1,774.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,281.50
|
| Rate for Payer: Multiplan All |
$2,306.85
|
| Rate for Payer: OMNI Networks Commercial |
$1,774.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,281.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,408.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,901.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,357.55
|
| Rate for Payer: Zelis Auto |
$1,014.00
|
| Rate for Payer: Zelis Worker's Compensation |
$692.05
|
|
