|
IMOGAM RABIES-HT IM 150 UNIT/ML
|
Facility
|
IP
|
$2,842.00
|
|
|
Service Code
|
NDC 49281019020
|
| Hospital Charge Code |
3302341
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$775.87 |
| Max. Negotiated Rate |
$2,699.90 |
| Rate for Payer: Cash Price |
$1,705.20
|
| Rate for Payer: Cigna Commercial |
$2,415.70
|
| Rate for Payer: First Health Commercial |
$2,557.80
|
| Rate for Payer: First Health Workers Compensation |
$1,097.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,557.80
|
| Rate for Payer: GEHA Commercial |
$1,989.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,557.80
|
| Rate for Payer: Multiplan All |
$2,586.22
|
| Rate for Payer: OMNI Networks Commercial |
$1,989.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,557.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,699.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,131.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,643.06
|
| Rate for Payer: Zelis Auto |
$1,136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$775.87
|
|
|
IMOVAX RABIES VAC IM
|
Facility
|
OP
|
$2,108.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3302342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$266.63 |
| Max. Negotiated Rate |
$2,002.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$356.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,264.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$356.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$282.08
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$313.68
|
| Rate for Payer: Cash Price |
$1,264.80
|
| Rate for Payer: Cash Price |
$1,264.80
|
| Rate for Payer: Cigna Commercial |
$1,791.80
|
| Rate for Payer: First Health Commercial |
$1,897.20
|
| Rate for Payer: First Health Workers Compensation |
$813.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,897.20
|
| Rate for Payer: GEHA Commercial |
$345.05
|
| Rate for Payer: GEHA Medicare |
$313.68
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,897.20
|
| Rate for Payer: Humana ChoiceCare |
$345.05
|
| Rate for Payer: Humana Medicare Advantage |
$313.68
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$526.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$287.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$313.68
|
| Rate for Payer: Multiplan All |
$1,918.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$533.26
|
| Rate for Payer: OMNI Networks Commercial |
$1,475.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,897.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$332.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$287.82
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$313.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,002.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$627.36
|
| Rate for Payer: Three Rivers Provider Network All |
$1,581.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$307.41
|
| Rate for Payer: United Healthcare Managed Medicaid |
$287.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,960.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$313.68
|
| Rate for Payer: Zelis Auto |
$843.20
|
| Rate for Payer: Zelis Medicare |
$266.63
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$376.42
|
| Rate for Payer: Zelis Worker's Compensation |
$575.48
|
|
|
IMOVAX RABIES VAC IM
|
Facility
|
IP
|
$2,108.00
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
3302342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$575.48 |
| Max. Negotiated Rate |
$2,002.60 |
| Rate for Payer: Cash Price |
$1,264.80
|
| Rate for Payer: Cigna Commercial |
$1,791.80
|
| Rate for Payer: First Health Commercial |
$1,897.20
|
| Rate for Payer: First Health Workers Compensation |
$813.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,897.20
|
| Rate for Payer: GEHA Commercial |
$1,475.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,897.20
|
| Rate for Payer: Multiplan All |
$1,918.28
|
| Rate for Payer: OMNI Networks Commercial |
$1,475.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,897.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,002.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,581.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,960.44
|
| Rate for Payer: Zelis Auto |
$843.20
|
| Rate for Payer: Zelis Worker's Compensation |
$575.48
|
|
|
IMPLANT BIOPRO HEMI MED 20MM
|
Facility
|
OP
|
$6,090.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.50 |
| Max. Negotiated Rate |
$5,785.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cigna Commercial |
$5,176.50
|
| Rate for Payer: First Health Commercial |
$5,481.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,481.00
|
| Rate for Payer: GEHA Commercial |
$4,872.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,481.00
|
| Rate for Payer: Humana ChoiceCare |
$1,583.40
|
| Rate for Payer: Multiplan All |
$5,541.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,654.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,263.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,481.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,785.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,359.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,522.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,663.70
|
| Rate for Payer: Zelis Auto |
$2,436.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,045.00
|
|
|
IMPLANT BIOPRO HEMI MED 20MM
|
Facility
|
IP
|
$6,090.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,436.00 |
| Max. Negotiated Rate |
$5,785.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,872.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cigna Commercial |
$5,176.50
|
| Rate for Payer: First Health Commercial |
$5,481.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,481.00
|
| Rate for Payer: GEHA Commercial |
$4,263.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,481.00
|
| Rate for Payer: Multiplan All |
$5,541.90
|
| Rate for Payer: OMNI Networks Commercial |
$4,263.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,481.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,785.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,567.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,663.70
|
| Rate for Payer: Zelis Auto |
$2,436.00
|
|
|
IMPLANT BRAIN ELECTRODES
|
Facility
|
OP
|
$3,415.00
|
|
|
Service Code
|
CPT 61760
|
| Hospital Charge Code |
6161760
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$853.75 |
| Max. Negotiated Rate |
$3,244.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,049.00
|
| Rate for Payer: Cash Price |
$2,049.00
|
| Rate for Payer: Cigna Commercial |
$2,902.75
|
| Rate for Payer: First Health Commercial |
$3,073.50
|
| Rate for Payer: First Health Workers Compensation |
$1,318.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,073.50
|
| Rate for Payer: GEHA Commercial |
$2,732.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,073.50
|
| Rate for Payer: Humana ChoiceCare |
$887.90
|
| Rate for Payer: Multiplan All |
$3,107.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,049.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,390.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,073.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,244.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,561.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,005.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$853.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,175.95
|
| Rate for Payer: Zelis Auto |
$1,366.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,707.50
|
| Rate for Payer: Zelis Worker's Compensation |
$932.29
|
|
|
IMPLANT BRAIN ELECTRODES
|
Facility
|
IP
|
$3,415.00
|
|
|
Service Code
|
CPT 61760
|
| Hospital Charge Code |
6161760
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$932.29 |
| Max. Negotiated Rate |
$3,244.25 |
| Rate for Payer: Cash Price |
$2,049.00
|
| Rate for Payer: Cigna Commercial |
$2,902.75
|
| Rate for Payer: First Health Commercial |
$3,073.50
|
| Rate for Payer: First Health Workers Compensation |
$1,318.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,073.50
|
| Rate for Payer: GEHA Commercial |
$2,390.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,073.50
|
| Rate for Payer: Multiplan All |
$3,107.65
|
| Rate for Payer: OMNI Networks Commercial |
$2,390.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,073.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,244.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,561.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,175.95
|
| Rate for Payer: Zelis Auto |
$1,366.00
|
| Rate for Payer: Zelis Worker's Compensation |
$932.29
|
|
|
IMPLANT HORMONE PELLET(S)
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 11980
|
| Hospital Charge Code |
6111980
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$166.25 |
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$148.75
|
| Rate for Payer: First Health Commercial |
$157.50
|
| Rate for Payer: First Health Workers Compensation |
$67.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$157.50
|
| Rate for Payer: GEHA Commercial |
$122.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$157.50
|
| Rate for Payer: Multiplan All |
$159.25
|
| Rate for Payer: OMNI Networks Commercial |
$122.50
|
| Rate for Payer: One Health Plan PPO/POS |
$157.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$166.25
|
| Rate for Payer: Three Rivers Provider Network All |
$131.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$162.75
|
| Rate for Payer: Zelis Auto |
$70.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.77
|
|
|
IMPLANT HORMONE PELLET(S)
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 11980
|
| Hospital Charge Code |
6111980
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$757.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$105.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$197.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$156.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$378.90
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$148.75
|
| Rate for Payer: First Health Commercial |
$157.50
|
| Rate for Payer: First Health Workers Compensation |
$67.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$157.50
|
| Rate for Payer: GEHA Commercial |
$140.00
|
| Rate for Payer: GEHA Medicare |
$378.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$157.50
|
| Rate for Payer: Humana ChoiceCare |
$416.79
|
| Rate for Payer: Humana Medicare Advantage |
$378.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$636.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$378.90
|
| Rate for Payer: Multiplan All |
$159.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$644.13
|
| Rate for Payer: OMNI Networks Commercial |
$122.50
|
| Rate for Payer: One Health Plan PPO/POS |
$157.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$184.37
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$159.67
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$378.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$166.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$757.80
|
| Rate for Payer: Three Rivers Provider Network All |
$131.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$371.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$378.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$162.75
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$378.90
|
| Rate for Payer: Zelis Auto |
$70.00
|
| Rate for Payer: Zelis Medicare |
$322.06
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$454.68
|
| Rate for Payer: Zelis Worker's Compensation |
$47.77
|
|
|
IMPLANT K-WIRE .9
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009091
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.80 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$181.60
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$158.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
|
|
IMPLANT K-WIRE .9
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009091
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.75 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cigna Commercial |
$192.95
|
| Rate for Payer: First Health Commercial |
$204.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$204.30
|
| Rate for Payer: GEHA Commercial |
$181.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$204.30
|
| Rate for Payer: Humana ChoiceCare |
$59.02
|
| Rate for Payer: Multiplan All |
$206.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$136.20
|
| Rate for Payer: OMNI Networks Commercial |
$158.90
|
| Rate for Payer: One Health Plan PPO/POS |
$204.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$215.65
|
| Rate for Payer: Three Rivers Provider Network All |
$170.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$199.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$56.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$211.11
|
| Rate for Payer: Zelis Auto |
$90.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$113.50
|
|
|
IMPLANT NERVE END
|
Facility
|
IP
|
$633.00
|
|
|
Service Code
|
CPT 64787
|
| Hospital Charge Code |
6164787
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$172.81 |
| Max. Negotiated Rate |
$601.35 |
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cigna Commercial |
$538.05
|
| Rate for Payer: First Health Commercial |
$569.70
|
| Rate for Payer: First Health Workers Compensation |
$244.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$569.70
|
| Rate for Payer: GEHA Commercial |
$443.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$569.70
|
| Rate for Payer: Multiplan All |
$576.03
|
| Rate for Payer: OMNI Networks Commercial |
$443.10
|
| Rate for Payer: One Health Plan PPO/POS |
$569.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$601.35
|
| Rate for Payer: Three Rivers Provider Network All |
$474.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$588.69
|
| Rate for Payer: Zelis Auto |
$253.20
|
| Rate for Payer: Zelis Worker's Compensation |
$172.81
|
|
|
IMPLANT NERVE END
|
Facility
|
OP
|
$633.00
|
|
|
Service Code
|
CPT 64787
|
| Hospital Charge Code |
6164787
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$164.58 |
| Max. Negotiated Rate |
$1,892.76 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$379.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,892.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,499.44
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Cigna Commercial |
$538.05
|
| Rate for Payer: First Health Commercial |
$569.70
|
| Rate for Payer: First Health Workers Compensation |
$244.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$569.70
|
| Rate for Payer: GEHA Commercial |
$506.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$569.70
|
| Rate for Payer: Humana ChoiceCare |
$164.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,529.98
|
| Rate for Payer: Multiplan All |
$576.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$379.80
|
| Rate for Payer: OMNI Networks Commercial |
$443.10
|
| Rate for Payer: One Health Plan PPO/POS |
$569.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,766.58
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,529.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$601.35
|
| Rate for Payer: Three Rivers Provider Network All |
$474.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$557.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,529.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$588.69
|
| Rate for Payer: Zelis Auto |
$253.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$316.50
|
| Rate for Payer: Zelis Worker's Compensation |
$172.81
|
|
|
IMPLANT NEUROELECTRDE ADDL
|
Facility
|
OP
|
$1,090.00
|
|
|
Service Code
|
CPT 61868
|
| Hospital Charge Code |
6161868
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$272.50 |
| Max. Negotiated Rate |
$1,035.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$654.00
|
| Rate for Payer: Cash Price |
$654.00
|
| Rate for Payer: Cigna Commercial |
$926.50
|
| Rate for Payer: First Health Commercial |
$981.00
|
| Rate for Payer: First Health Workers Compensation |
$420.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$981.00
|
| Rate for Payer: GEHA Commercial |
$872.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$981.00
|
| Rate for Payer: Humana ChoiceCare |
$283.40
|
| Rate for Payer: Multiplan All |
$991.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$654.00
|
| Rate for Payer: OMNI Networks Commercial |
$763.00
|
| Rate for Payer: One Health Plan PPO/POS |
$981.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,035.50
|
| Rate for Payer: Three Rivers Provider Network All |
$817.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$959.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$272.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,013.70
|
| Rate for Payer: Zelis Auto |
$436.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$545.00
|
| Rate for Payer: Zelis Worker's Compensation |
$297.57
|
|
|
IMPLANT NEUROELECTRDE ADDL
|
Facility
|
IP
|
$1,090.00
|
|
|
Service Code
|
CPT 61868
|
| Hospital Charge Code |
6161868
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$297.57 |
| Max. Negotiated Rate |
$1,035.50 |
| Rate for Payer: Cash Price |
$654.00
|
| Rate for Payer: Cigna Commercial |
$926.50
|
| Rate for Payer: First Health Commercial |
$981.00
|
| Rate for Payer: First Health Workers Compensation |
$420.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$981.00
|
| Rate for Payer: GEHA Commercial |
$763.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$981.00
|
| Rate for Payer: Multiplan All |
$991.90
|
| Rate for Payer: OMNI Networks Commercial |
$763.00
|
| Rate for Payer: One Health Plan PPO/POS |
$981.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,035.50
|
| Rate for Payer: Three Rivers Provider Network All |
$817.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,013.70
|
| Rate for Payer: Zelis Auto |
$436.00
|
| Rate for Payer: Zelis Worker's Compensation |
$297.57
|
|
|
IMPLANT NEUROELECTRDE ADDL
|
Facility
|
IP
|
$777.00
|
|
|
Service Code
|
CPT 61864
|
| Hospital Charge Code |
6161864
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$212.12 |
| Max. Negotiated Rate |
$738.15 |
| Rate for Payer: Cash Price |
$466.20
|
| Rate for Payer: Cigna Commercial |
$660.45
|
| Rate for Payer: First Health Commercial |
$699.30
|
| Rate for Payer: First Health Workers Compensation |
$300.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$699.30
|
| Rate for Payer: GEHA Commercial |
$543.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$699.30
|
| Rate for Payer: Multiplan All |
$707.07
|
| Rate for Payer: OMNI Networks Commercial |
$543.90
|
| Rate for Payer: One Health Plan PPO/POS |
$699.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$738.15
|
| Rate for Payer: Three Rivers Provider Network All |
$582.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$722.61
|
| Rate for Payer: Zelis Auto |
$310.80
|
| Rate for Payer: Zelis Worker's Compensation |
$212.12
|
|
|
IMPLANT NEUROELECTRDE ADDL
|
Facility
|
OP
|
$777.00
|
|
|
Service Code
|
CPT 61864
|
| Hospital Charge Code |
6161864
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$738.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$466.20
|
| Rate for Payer: Cash Price |
$466.20
|
| Rate for Payer: Cigna Commercial |
$660.45
|
| Rate for Payer: First Health Commercial |
$699.30
|
| Rate for Payer: First Health Workers Compensation |
$300.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$699.30
|
| Rate for Payer: GEHA Commercial |
$621.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$699.30
|
| Rate for Payer: Humana ChoiceCare |
$202.02
|
| Rate for Payer: Multiplan All |
$707.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$466.20
|
| Rate for Payer: OMNI Networks Commercial |
$543.90
|
| Rate for Payer: One Health Plan PPO/POS |
$699.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$738.15
|
| Rate for Payer: Three Rivers Provider Network All |
$582.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$683.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$722.61
|
| Rate for Payer: Zelis Auto |
$310.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$388.50
|
| Rate for Payer: Zelis Worker's Compensation |
$212.12
|
|
|
IMPLANT NEUROELECTRODE
|
Facility
|
OP
|
$4,909.00
|
|
|
Service Code
|
CPT 61867
|
| Hospital Charge Code |
6161867
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,227.25 |
| Max. Negotiated Rate |
$4,663.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,945.40
|
| Rate for Payer: Cash Price |
$2,945.40
|
| Rate for Payer: Cigna Commercial |
$4,172.65
|
| Rate for Payer: First Health Commercial |
$4,418.10
|
| Rate for Payer: First Health Workers Compensation |
$1,895.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,418.10
|
| Rate for Payer: GEHA Commercial |
$3,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,418.10
|
| Rate for Payer: Humana ChoiceCare |
$1,276.34
|
| Rate for Payer: Multiplan All |
$4,467.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,945.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,436.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,418.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,663.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,681.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,319.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,227.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,565.37
|
| Rate for Payer: Zelis Auto |
$1,963.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,454.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,340.16
|
|
|
IMPLANT NEUROELECTRODE
|
Facility
|
IP
|
$4,909.00
|
|
|
Service Code
|
CPT 61867
|
| Hospital Charge Code |
6161867
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,340.16 |
| Max. Negotiated Rate |
$4,663.55 |
| Rate for Payer: Cash Price |
$2,945.40
|
| Rate for Payer: Cigna Commercial |
$4,172.65
|
| Rate for Payer: First Health Commercial |
$4,418.10
|
| Rate for Payer: First Health Workers Compensation |
$1,895.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,418.10
|
| Rate for Payer: GEHA Commercial |
$3,436.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,418.10
|
| Rate for Payer: Multiplan All |
$4,467.19
|
| Rate for Payer: OMNI Networks Commercial |
$3,436.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,418.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,663.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,681.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,565.37
|
| Rate for Payer: Zelis Auto |
$1,963.60
|
| Rate for Payer: Zelis Worker's Compensation |
$1,340.16
|
|
|
IMPLANT NEUROELECTRODE
|
Facility
|
IP
|
$3,220.00
|
|
|
Service Code
|
CPT 61863
|
| Hospital Charge Code |
6161863
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$879.06 |
| Max. Negotiated Rate |
$3,059.00 |
| Rate for Payer: Cash Price |
$1,932.00
|
| Rate for Payer: Cigna Commercial |
$2,737.00
|
| Rate for Payer: First Health Commercial |
$2,898.00
|
| Rate for Payer: First Health Workers Compensation |
$1,243.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,898.00
|
| Rate for Payer: GEHA Commercial |
$2,254.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,898.00
|
| Rate for Payer: Multiplan All |
$2,930.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,254.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,898.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,059.00
|
| Rate for Payer: Three Rivers Provider Network All |
$2,415.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,994.60
|
| Rate for Payer: Zelis Auto |
$1,288.00
|
| Rate for Payer: Zelis Worker's Compensation |
$879.06
|
|
|
IMPLANT NEUROELECTRODE
|
Facility
|
OP
|
$3,220.00
|
|
|
Service Code
|
CPT 61863
|
| Hospital Charge Code |
6161863
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$805.00 |
| Max. Negotiated Rate |
$3,059.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,932.00
|
| Rate for Payer: Cash Price |
$1,932.00
|
| Rate for Payer: Cigna Commercial |
$2,737.00
|
| Rate for Payer: First Health Commercial |
$2,898.00
|
| Rate for Payer: First Health Workers Compensation |
$1,243.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,898.00
|
| Rate for Payer: GEHA Commercial |
$2,576.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,898.00
|
| Rate for Payer: Humana ChoiceCare |
$837.20
|
| Rate for Payer: Multiplan All |
$2,930.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,932.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,254.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,898.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,059.00
|
| Rate for Payer: Three Rivers Provider Network All |
$2,415.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,833.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$805.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,994.60
|
| Rate for Payer: Zelis Auto |
$1,288.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,610.00
|
| Rate for Payer: Zelis Worker's Compensation |
$879.06
|
|
|
IMPLANT NEUROELECTRODES
|
Facility
|
OP
|
$1,281.00
|
|
|
Service Code
|
CPT 63650
|
| Hospital Charge Code |
6163650
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$349.71 |
| Max. Negotiated Rate |
$12,463.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6,643.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$768.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$6,643.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$5,263.23
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,231.74
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$1,088.85
|
| Rate for Payer: First Health Commercial |
$1,152.90
|
| Rate for Payer: First Health Workers Compensation |
$494.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,152.90
|
| Rate for Payer: GEHA Commercial |
$1,024.80
|
| Rate for Payer: GEHA Medicare |
$6,231.74
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,152.90
|
| Rate for Payer: Humana ChoiceCare |
$6,854.91
|
| Rate for Payer: Humana Medicare Advantage |
$6,231.74
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10,469.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5,370.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,231.74
|
| Rate for Payer: Multiplan All |
$1,165.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,593.96
|
| Rate for Payer: OMNI Networks Commercial |
$896.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,152.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$6,200.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5,370.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,231.74
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,216.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$12,463.48
|
| Rate for Payer: Three Rivers Provider Network All |
$960.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,107.11
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,370.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,231.74
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,191.33
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,231.74
|
| Rate for Payer: Zelis Auto |
$512.40
|
| Rate for Payer: Zelis Medicare |
$5,296.98
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,478.09
|
| Rate for Payer: Zelis Worker's Compensation |
$349.71
|
|
|
IMPLANT NEUROELECTRODES
|
Facility
|
OP
|
$3,383.00
|
|
|
Service Code
|
CPT 61860
|
| Hospital Charge Code |
6161860
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$845.75 |
| Max. Negotiated Rate |
$3,213.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,029.80
|
| Rate for Payer: Cash Price |
$2,029.80
|
| Rate for Payer: Cigna Commercial |
$2,875.55
|
| Rate for Payer: First Health Commercial |
$3,044.70
|
| Rate for Payer: First Health Workers Compensation |
$1,306.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,044.70
|
| Rate for Payer: GEHA Commercial |
$2,706.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,044.70
|
| Rate for Payer: Humana ChoiceCare |
$879.58
|
| Rate for Payer: Multiplan All |
$3,078.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,029.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,368.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,044.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,213.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,537.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,977.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$845.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,146.19
|
| Rate for Payer: Zelis Auto |
$1,353.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,691.50
|
| Rate for Payer: Zelis Worker's Compensation |
$923.56
|
|
|
IMPLANT NEUROELECTRODES
|
Facility
|
IP
|
$1,738.00
|
|
|
Service Code
|
CPT 63655
|
| Hospital Charge Code |
6163655
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$474.47 |
| Max. Negotiated Rate |
$1,651.10 |
| Rate for Payer: Cash Price |
$1,042.80
|
| Rate for Payer: Cigna Commercial |
$1,477.30
|
| Rate for Payer: First Health Commercial |
$1,564.20
|
| Rate for Payer: First Health Workers Compensation |
$671.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,564.20
|
| Rate for Payer: GEHA Commercial |
$1,216.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,564.20
|
| Rate for Payer: Multiplan All |
$1,581.58
|
| Rate for Payer: OMNI Networks Commercial |
$1,216.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,564.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,651.10
|
| Rate for Payer: Three Rivers Provider Network All |
$1,303.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,616.34
|
| Rate for Payer: Zelis Auto |
$695.20
|
| Rate for Payer: Zelis Worker's Compensation |
$474.47
|
|
|
IMPLANT NEUROELECTRODES
|
Facility
|
OP
|
$819.00
|
|
|
Service Code
|
CPT 64575
|
| Hospital Charge Code |
6164575
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$23,682.12 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$491.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11,841.06
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: Cigna Commercial |
$696.15
|
| Rate for Payer: First Health Commercial |
$737.10
|
| Rate for Payer: First Health Workers Compensation |
$316.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$737.10
|
| Rate for Payer: GEHA Commercial |
$655.20
|
| Rate for Payer: GEHA Medicare |
$11,841.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$737.10
|
| Rate for Payer: Humana ChoiceCare |
$13,025.17
|
| Rate for Payer: Humana Medicare Advantage |
$11,841.06
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19,892.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11,841.06
|
| Rate for Payer: Multiplan All |
$745.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20,129.80
|
| Rate for Payer: OMNI Networks Commercial |
$573.30
|
| Rate for Payer: One Health Plan PPO/POS |
$737.10
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11,841.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$778.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23,682.12
|
| Rate for Payer: Three Rivers Provider Network All |
$614.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,604.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$204.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,841.06
|
| Rate for Payer: United Payors & United Providers UP&UP |
$761.67
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11,841.06
|
| Rate for Payer: Zelis Auto |
$327.60
|
| Rate for Payer: Zelis Medicare |
$10,064.90
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14,209.27
|
| Rate for Payer: Zelis Worker's Compensation |
$223.59
|
|
