|
GRAFIX 1.6CM DISC GRAFIXPL
|
Facility
|
IP
|
$1,959.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$783.60 |
| Max. Negotiated Rate |
$1,861.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,567.20
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cigna Commercial |
$1,665.15
|
| Rate for Payer: First Health Commercial |
$1,763.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,763.10
|
| Rate for Payer: GEHA Commercial |
$1,371.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,763.10
|
| Rate for Payer: Multiplan All |
$1,782.69
|
| Rate for Payer: OMNI Networks Commercial |
$1,371.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,763.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,861.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,469.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,821.87
|
| Rate for Payer: Zelis Auto |
$783.60
|
|
|
GRAFIX PRIME PL 3 X 4 CM
|
Facility
|
IP
|
$8,983.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006361
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,452.36 |
| Max. Negotiated Rate |
$8,533.85 |
| Rate for Payer: Cash Price |
$5,389.80
|
| Rate for Payer: Cigna Commercial |
$7,635.55
|
| Rate for Payer: First Health Commercial |
$8,084.70
|
| Rate for Payer: First Health Workers Compensation |
$3,468.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,084.70
|
| Rate for Payer: GEHA Commercial |
$6,288.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,084.70
|
| Rate for Payer: Multiplan All |
$8,174.53
|
| Rate for Payer: OMNI Networks Commercial |
$6,288.10
|
| Rate for Payer: One Health Plan PPO/POS |
$8,084.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,533.85
|
| Rate for Payer: Three Rivers Provider Network All |
$6,737.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,354.19
|
| Rate for Payer: Zelis Auto |
$3,593.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2,452.36
|
|
|
GRAFIX PRIME PL 3 X 4 CM
|
Facility
|
OP
|
$8,983.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006361
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$8,533.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,389.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$5,389.80
|
| Rate for Payer: Cash Price |
$5,389.80
|
| Rate for Payer: Cigna Commercial |
$7,635.55
|
| Rate for Payer: First Health Commercial |
$8,084.70
|
| Rate for Payer: First Health Workers Compensation |
$3,468.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,084.70
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,084.70
|
| Rate for Payer: Humana ChoiceCare |
$2,335.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$8,174.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,389.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,288.10
|
| Rate for Payer: One Health Plan PPO/POS |
$8,084.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,533.85
|
| Rate for Payer: Three Rivers Provider Network All |
$6,737.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,905.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,354.19
|
| Rate for Payer: Zelis Auto |
$3,593.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,491.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2,452.36
|
|
|
GRAFIX PRIME PL SQ CM 1.5 X 2 CM
|
Facility
|
OP
|
$2,522.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7002605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$2,395.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,513.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cigna Commercial |
$2,143.70
|
| Rate for Payer: First Health Commercial |
$2,269.80
|
| Rate for Payer: First Health Workers Compensation |
$973.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,269.80
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,269.80
|
| Rate for Payer: Humana ChoiceCare |
$655.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$2,295.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,765.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,269.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,395.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,891.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,219.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,345.46
|
| Rate for Payer: Zelis Auto |
$1,008.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,261.00
|
| Rate for Payer: Zelis Worker's Compensation |
$688.51
|
|
|
GRAFIX PRIME PL SQ CM 1.5 X 2 CM
|
Facility
|
IP
|
$2,522.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7002605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$688.51 |
| Max. Negotiated Rate |
$2,395.90 |
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cigna Commercial |
$2,143.70
|
| Rate for Payer: First Health Commercial |
$2,269.80
|
| Rate for Payer: First Health Workers Compensation |
$973.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,269.80
|
| Rate for Payer: GEHA Commercial |
$1,765.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,269.80
|
| Rate for Payer: Multiplan All |
$2,295.02
|
| Rate for Payer: OMNI Networks Commercial |
$1,765.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,269.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,395.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,891.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,345.46
|
| Rate for Payer: Zelis Auto |
$1,008.80
|
| Rate for Payer: Zelis Worker's Compensation |
$688.51
|
|
|
GRAFIX PRIME PL SQ CM 2X3
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,173.90 |
| Max. Negotiated Rate |
$4,085.00 |
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cigna Commercial |
$3,655.00
|
| Rate for Payer: First Health Commercial |
$3,870.00
|
| Rate for Payer: First Health Workers Compensation |
$1,660.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,870.00
|
| Rate for Payer: GEHA Commercial |
$3,010.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,870.00
|
| Rate for Payer: Multiplan All |
$3,913.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,010.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,870.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,085.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,225.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,999.00
|
| Rate for Payer: Zelis Auto |
$1,720.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,173.90
|
|
|
GRAFIX PRIME PL SQ CM 2X3
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$4,085.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,580.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cigna Commercial |
$3,655.00
|
| Rate for Payer: First Health Commercial |
$3,870.00
|
| Rate for Payer: First Health Workers Compensation |
$1,660.23
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,870.00
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,870.00
|
| Rate for Payer: Humana ChoiceCare |
$1,118.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$3,913.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,580.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,010.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,870.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,085.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,225.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,784.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,999.00
|
| Rate for Payer: Zelis Auto |
$1,720.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,150.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,173.90
|
|
|
GRAFIX PRIME PL SQ CM 5X 5 CM
|
Facility
|
OP
|
$2,522.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$2,395.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,513.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cigna Commercial |
$2,143.70
|
| Rate for Payer: First Health Commercial |
$2,269.80
|
| Rate for Payer: First Health Workers Compensation |
$973.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,269.80
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,269.80
|
| Rate for Payer: Humana ChoiceCare |
$655.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$2,295.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,765.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,269.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,395.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,891.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,219.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,345.46
|
| Rate for Payer: Zelis Auto |
$1,008.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,261.00
|
| Rate for Payer: Zelis Worker's Compensation |
$688.51
|
|
|
GRAFIX PRIME PL SQ CM 5X 5 CM
|
Facility
|
IP
|
$2,522.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$688.51 |
| Max. Negotiated Rate |
$2,395.90 |
| Rate for Payer: Cash Price |
$1,513.20
|
| Rate for Payer: Cigna Commercial |
$2,143.70
|
| Rate for Payer: First Health Commercial |
$2,269.80
|
| Rate for Payer: First Health Workers Compensation |
$973.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,269.80
|
| Rate for Payer: GEHA Commercial |
$1,765.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,269.80
|
| Rate for Payer: Multiplan All |
$2,295.02
|
| Rate for Payer: OMNI Networks Commercial |
$1,765.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,269.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,395.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,891.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,345.46
|
| Rate for Payer: Zelis Auto |
$1,008.80
|
| Rate for Payer: Zelis Worker's Compensation |
$688.51
|
|
|
GRAFIX STRAVIX PRIME PL SQCM
|
Facility
|
OP
|
$1,243.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
1994133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$1,180.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$745.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cigna Commercial |
$1,056.55
|
| Rate for Payer: First Health Commercial |
$1,118.70
|
| Rate for Payer: First Health Workers Compensation |
$479.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,118.70
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,118.70
|
| Rate for Payer: Humana ChoiceCare |
$323.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$1,131.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$745.80
|
| Rate for Payer: OMNI Networks Commercial |
$870.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,118.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,180.85
|
| Rate for Payer: Three Rivers Provider Network All |
$932.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,093.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,155.99
|
| Rate for Payer: Zelis Auto |
$497.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$621.50
|
| Rate for Payer: Zelis Worker's Compensation |
$339.34
|
|
|
GRAFIX STRAVIX PRIME PL SQCM
|
Facility
|
IP
|
$1,243.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
1994133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$339.34 |
| Max. Negotiated Rate |
$1,180.85 |
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cigna Commercial |
$1,056.55
|
| Rate for Payer: First Health Commercial |
$1,118.70
|
| Rate for Payer: First Health Workers Compensation |
$479.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,118.70
|
| Rate for Payer: GEHA Commercial |
$870.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,118.70
|
| Rate for Payer: Multiplan All |
$1,131.13
|
| Rate for Payer: OMNI Networks Commercial |
$870.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,118.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,180.85
|
| Rate for Payer: Three Rivers Provider Network All |
$932.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,155.99
|
| Rate for Payer: Zelis Auto |
$497.20
|
| Rate for Payer: Zelis Worker's Compensation |
$339.34
|
|
|
GRAFIX STRAVIX PRIME PL SQ CM5X5
|
Facility
|
IP
|
$1,726.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$471.20 |
| Max. Negotiated Rate |
$1,639.70 |
| Rate for Payer: Cash Price |
$1,035.60
|
| Rate for Payer: Cigna Commercial |
$1,467.10
|
| Rate for Payer: First Health Commercial |
$1,553.40
|
| Rate for Payer: First Health Workers Compensation |
$666.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,553.40
|
| Rate for Payer: GEHA Commercial |
$1,208.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,553.40
|
| Rate for Payer: Multiplan All |
$1,570.66
|
| Rate for Payer: OMNI Networks Commercial |
$1,208.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,553.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,639.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,294.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,605.18
|
| Rate for Payer: Zelis Auto |
$690.40
|
| Rate for Payer: Zelis Worker's Compensation |
$471.20
|
|
|
GRAFIX STRAVIX PRIME PL SQ CM5X5
|
Facility
|
OP
|
$1,726.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7005193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$1,639.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,035.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$1,035.60
|
| Rate for Payer: Cash Price |
$1,035.60
|
| Rate for Payer: Cigna Commercial |
$1,467.10
|
| Rate for Payer: First Health Commercial |
$1,553.40
|
| Rate for Payer: First Health Workers Compensation |
$666.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,553.40
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,553.40
|
| Rate for Payer: Humana ChoiceCare |
$448.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$1,570.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,035.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,208.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,553.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,639.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,294.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,518.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,605.18
|
| Rate for Payer: Zelis Auto |
$690.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$863.00
|
| Rate for Payer: Zelis Worker's Compensation |
$471.20
|
|
|
GRAFIX STRAVIX PRIME PL SQ CM SAMPLE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
9605293
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$221.49 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
GRAFIX STRAVIX PRIME PL SQ CM SAMPLE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
9605293
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$0.01
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
|
GRAFT HAND OR FINGER TENDON
|
Facility
|
IP
|
$1,450.00
|
|
|
Service Code
|
CPT 26416
|
| Hospital Charge Code |
6126416
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$395.85 |
| Max. Negotiated Rate |
$1,377.50 |
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cigna Commercial |
$1,232.50
|
| Rate for Payer: First Health Commercial |
$1,305.00
|
| Rate for Payer: First Health Workers Compensation |
$559.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,305.00
|
| Rate for Payer: GEHA Commercial |
$1,015.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,305.00
|
| Rate for Payer: Multiplan All |
$1,319.50
|
| Rate for Payer: OMNI Networks Commercial |
$1,015.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,305.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,377.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,087.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,348.50
|
| Rate for Payer: Zelis Auto |
$580.00
|
| Rate for Payer: Zelis Worker's Compensation |
$395.85
|
|
|
GRAFT HAND OR FINGER TENDON
|
Facility
|
OP
|
$1,450.00
|
|
|
Service Code
|
CPT 26416
|
| Hospital Charge Code |
6126416
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$395.85 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$870.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,261.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cigna Commercial |
$1,232.50
|
| Rate for Payer: First Health Commercial |
$1,305.00
|
| Rate for Payer: First Health Workers Compensation |
$559.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,305.00
|
| Rate for Payer: GEHA Commercial |
$1,160.00
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,305.00
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,307.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,319.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$1,015.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,305.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,664.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,307.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,377.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$1,087.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,307.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,348.50
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$580.00
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$395.85
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO 25 CC/<
|
Facility
|
IP
|
$1,495.00
|
|
|
Service Code
|
CPT 15773
|
| Hospital Charge Code |
6115773
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$408.13 |
| Max. Negotiated Rate |
$1,420.25 |
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,270.75
|
| Rate for Payer: First Health Commercial |
$1,345.50
|
| Rate for Payer: First Health Workers Compensation |
$577.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,345.50
|
| Rate for Payer: GEHA Commercial |
$1,046.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,345.50
|
| Rate for Payer: Multiplan All |
$1,360.45
|
| Rate for Payer: OMNI Networks Commercial |
$1,046.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,345.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,420.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,390.35
|
| Rate for Payer: Zelis Auto |
$598.00
|
| Rate for Payer: Zelis Worker's Compensation |
$408.13
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO 25 CC/<
|
Facility
|
OP
|
$1,495.00
|
|
|
Service Code
|
CPT 15773
|
| Hospital Charge Code |
6115773
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$408.13 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,434.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$897.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,434.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,928.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,270.75
|
| Rate for Payer: First Health Commercial |
$1,345.50
|
| Rate for Payer: First Health Workers Compensation |
$577.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,345.50
|
| Rate for Payer: GEHA Commercial |
$1,196.00
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,345.50
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,967.57
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,360.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,046.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,345.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,271.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,967.57
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,420.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,121.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,967.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,390.35
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$598.00
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$408.13
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO 50CC/<
|
Facility
|
IP
|
$1,479.00
|
|
|
Service Code
|
CPT 15771
|
| Hospital Charge Code |
6115771
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$403.77 |
| Max. Negotiated Rate |
$1,405.05 |
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cigna Commercial |
$1,257.15
|
| Rate for Payer: First Health Commercial |
$1,331.10
|
| Rate for Payer: First Health Workers Compensation |
$571.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,331.10
|
| Rate for Payer: GEHA Commercial |
$1,035.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,331.10
|
| Rate for Payer: Multiplan All |
$1,345.89
|
| Rate for Payer: OMNI Networks Commercial |
$1,035.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,331.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,405.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,109.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,375.47
|
| Rate for Payer: Zelis Auto |
$591.60
|
| Rate for Payer: Zelis Worker's Compensation |
$403.77
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO 50CC/<
|
Facility
|
OP
|
$1,479.00
|
|
|
Service Code
|
CPT 15771
|
| Hospital Charge Code |
6115771
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$403.77 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,465.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$887.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,465.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,537.91
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cigna Commercial |
$1,257.15
|
| Rate for Payer: First Health Commercial |
$1,331.10
|
| Rate for Payer: First Health Workers Compensation |
$571.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,331.10
|
| Rate for Payer: GEHA Commercial |
$1,183.20
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,331.10
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,609.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,345.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,035.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,331.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,168.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,609.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,405.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,109.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,609.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,375.47
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$591.60
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$403.77
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO EA AD 25
|
Facility
|
IP
|
$427.00
|
|
|
Service Code
|
CPT 15774
|
| Hospital Charge Code |
6115774
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$116.57 |
| Max. Negotiated Rate |
$405.65 |
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$362.95
|
| Rate for Payer: First Health Commercial |
$384.30
|
| Rate for Payer: First Health Workers Compensation |
$164.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$384.30
|
| Rate for Payer: GEHA Commercial |
$298.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$384.30
|
| Rate for Payer: Multiplan All |
$388.57
|
| Rate for Payer: OMNI Networks Commercial |
$298.90
|
| Rate for Payer: One Health Plan PPO/POS |
$384.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$405.65
|
| Rate for Payer: Three Rivers Provider Network All |
$320.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$397.11
|
| Rate for Payer: Zelis Auto |
$170.80
|
| Rate for Payer: Zelis Worker's Compensation |
$116.57
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO EA AD 25
|
Facility
|
OP
|
$427.00
|
|
|
Service Code
|
CPT 15774
|
| Hospital Charge Code |
6115774
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$405.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$256.20
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$362.95
|
| Rate for Payer: First Health Commercial |
$384.30
|
| Rate for Payer: First Health Workers Compensation |
$164.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$384.30
|
| Rate for Payer: GEHA Commercial |
$341.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$384.30
|
| Rate for Payer: Humana ChoiceCare |
$111.02
|
| Rate for Payer: Multiplan All |
$388.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$256.20
|
| Rate for Payer: OMNI Networks Commercial |
$298.90
|
| Rate for Payer: One Health Plan PPO/POS |
$384.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$405.65
|
| Rate for Payer: Three Rivers Provider Network All |
$320.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$375.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$106.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$397.11
|
| Rate for Payer: Zelis Auto |
$170.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$213.50
|
| Rate for Payer: Zelis Worker's Compensation |
$116.57
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO EA AD 50
|
Facility
|
OP
|
$446.00
|
|
|
Service Code
|
CPT 15772
|
| Hospital Charge Code |
6115772
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$111.50 |
| Max. Negotiated Rate |
$423.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$267.60
|
| Rate for Payer: Cash Price |
$267.60
|
| Rate for Payer: Cigna Commercial |
$379.10
|
| Rate for Payer: First Health Commercial |
$401.40
|
| Rate for Payer: First Health Workers Compensation |
$172.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$401.40
|
| Rate for Payer: GEHA Commercial |
$356.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$401.40
|
| Rate for Payer: Humana ChoiceCare |
$115.96
|
| Rate for Payer: Multiplan All |
$405.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$267.60
|
| Rate for Payer: OMNI Networks Commercial |
$312.20
|
| Rate for Payer: One Health Plan PPO/POS |
$401.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$423.70
|
| Rate for Payer: Three Rivers Provider Network All |
$334.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$392.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$111.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$414.78
|
| Rate for Payer: Zelis Auto |
$178.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$223.00
|
| Rate for Payer: Zelis Worker's Compensation |
$121.76
|
|
|
GRAFT OF AUTOLOGOUS FAT BY LIPO EA AD 50
|
Facility
|
IP
|
$446.00
|
|
|
Service Code
|
CPT 15772
|
| Hospital Charge Code |
6115772
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$121.76 |
| Max. Negotiated Rate |
$423.70 |
| Rate for Payer: Cash Price |
$267.60
|
| Rate for Payer: Cigna Commercial |
$379.10
|
| Rate for Payer: First Health Commercial |
$401.40
|
| Rate for Payer: First Health Workers Compensation |
$172.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$401.40
|
| Rate for Payer: GEHA Commercial |
$312.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$401.40
|
| Rate for Payer: Multiplan All |
$405.86
|
| Rate for Payer: OMNI Networks Commercial |
$312.20
|
| Rate for Payer: One Health Plan PPO/POS |
$401.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$423.70
|
| Rate for Payer: Three Rivers Provider Network All |
$334.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$414.78
|
| Rate for Payer: Zelis Auto |
$178.40
|
| Rate for Payer: Zelis Worker's Compensation |
$121.76
|
|
