|
4.5MM CORTICAL SCREWS 35MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
4.5MM CORTICAL SCREWS 35MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
4.5MM CORTICAL SCREWS 375MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
4.5MM CORTICAL SCREWS 375MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008056
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
4.5MM CORTICAL SCREWS 40MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
4.5MM CORTICAL SCREWS 40MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
4.5MM CORTICAL SCREWS 42.5MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
4.5MM CORTICAL SCREWS 42.5MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
4.5MM CORTICAL SCREWS 45MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
4.5MM CORTICAL SCREWS 45MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
5.0 CANNULATED DRILL BIT ASNIS
|
Facility
|
IP
|
$1,337.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$365.00 |
| Max. Negotiated Rate |
$1,270.15 |
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$1,136.45
|
| Rate for Payer: First Health Commercial |
$1,203.30
|
| Rate for Payer: First Health Workers Compensation |
$516.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,203.30
|
| Rate for Payer: GEHA Commercial |
$935.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,203.30
|
| Rate for Payer: Multiplan All |
$1,216.67
|
| Rate for Payer: OMNI Networks Commercial |
$935.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,203.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,270.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,002.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,243.41
|
| Rate for Payer: Zelis Auto |
$534.80
|
| Rate for Payer: Zelis Worker's Compensation |
$365.00
|
|
|
5.0 CANNULATED DRILL BIT ASNIS
|
Facility
|
OP
|
$1,337.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7005192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$334.25 |
| Max. Negotiated Rate |
$1,270.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$802.20
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$1,136.45
|
| Rate for Payer: First Health Commercial |
$1,203.30
|
| Rate for Payer: First Health Workers Compensation |
$516.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,203.30
|
| Rate for Payer: GEHA Commercial |
$1,069.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,203.30
|
| Rate for Payer: Humana ChoiceCare |
$347.62
|
| Rate for Payer: Multiplan All |
$1,216.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$802.20
|
| Rate for Payer: OMNI Networks Commercial |
$935.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,203.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,270.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,002.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,176.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$334.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,243.41
|
| Rate for Payer: Zelis Auto |
$534.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$668.50
|
| Rate for Payer: Zelis Worker's Compensation |
$365.00
|
|
|
5-11 YRS
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
7299383
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$62.52 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$160.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
5-11 YRS
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
8599393
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
5-11 YRS
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
7299383
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$137.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$183.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Humana ChoiceCare |
$59.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$137.40
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$201.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.50
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
5-11 YRS
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
8599383
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$62.52 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$160.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
5-11 YRS
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
8599383
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$137.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$183.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Humana ChoiceCare |
$59.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$137.40
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$201.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.50
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
5-11 YRS
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
8599393
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
52310 CYSTOSCOPY AND TREATMENT FB
|
Facility
|
OP
|
$830.58
|
|
|
Service Code
|
CPT 52310
|
| Hospital Charge Code |
6152310
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$226.75 |
| Max. Negotiated Rate |
$3,890.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,722.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$498.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,722.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,364.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,945.14
|
| Rate for Payer: Cash Price |
$498.35
|
| Rate for Payer: Cash Price |
$498.35
|
| Rate for Payer: Cigna Commercial |
$705.99
|
| Rate for Payer: First Health Commercial |
$747.52
|
| Rate for Payer: First Health Workers Compensation |
$320.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$747.52
|
| Rate for Payer: GEHA Commercial |
$664.46
|
| Rate for Payer: GEHA Medicare |
$1,945.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$747.52
|
| Rate for Payer: Humana ChoiceCare |
$2,139.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,945.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$3,267.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,945.14
|
| Rate for Payer: Multiplan All |
$755.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,306.74
|
| Rate for Payer: OMNI Networks Commercial |
$581.41
|
| Rate for Payer: One Health Plan PPO/POS |
$747.52
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,607.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,945.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$789.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,890.28
|
| Rate for Payer: Three Rivers Provider Network All |
$622.93
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,906.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,945.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$772.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,945.14
|
| Rate for Payer: Zelis Auto |
$332.23
|
| Rate for Payer: Zelis Medicare |
$1,653.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,334.17
|
| Rate for Payer: Zelis Worker's Compensation |
$226.75
|
|
|
52310 CYSTOSCOPY AND TREATMENT FB
|
Facility
|
IP
|
$830.58
|
|
|
Service Code
|
CPT 52310
|
| Hospital Charge Code |
6152310
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$226.75 |
| Max. Negotiated Rate |
$789.05 |
| Rate for Payer: Cash Price |
$498.35
|
| Rate for Payer: Cigna Commercial |
$705.99
|
| Rate for Payer: First Health Commercial |
$747.52
|
| Rate for Payer: First Health Workers Compensation |
$320.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$747.52
|
| Rate for Payer: GEHA Commercial |
$581.41
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$747.52
|
| Rate for Payer: Multiplan All |
$755.83
|
| Rate for Payer: OMNI Networks Commercial |
$581.41
|
| Rate for Payer: One Health Plan PPO/POS |
$747.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$789.05
|
| Rate for Payer: Three Rivers Provider Network All |
$622.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$772.44
|
| Rate for Payer: Zelis Auto |
$332.23
|
| Rate for Payer: Zelis Worker's Compensation |
$226.75
|
|
|
5 HIAA 24hr urine quant REF004069
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
2200329
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.90
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$132.60
|
| Rate for Payer: First Health Commercial |
$140.40
|
| Rate for Payer: First Health Workers Compensation |
$24.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.40
|
| Rate for Payer: GEHA Commercial |
$124.80
|
| Rate for Payer: GEHA Medicare |
$12.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.40
|
| Rate for Payer: Humana ChoiceCare |
$14.19
|
| Rate for Payer: Humana Medicare Advantage |
$12.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.90
|
| Rate for Payer: Multiplan All |
$141.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.93
|
| Rate for Payer: OMNI Networks Commercial |
$109.20
|
| Rate for Payer: One Health Plan PPO/POS |
$140.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$25.80
|
| Rate for Payer: Three Rivers Provider Network All |
$117.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.64
|
| Rate for Payer: United Healthcare Commercial |
$132.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.90
|
| Rate for Payer: Zelis Auto |
$62.40
|
| Rate for Payer: Zelis Medicare |
$10.96
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.48
|
| Rate for Payer: Zelis Worker's Compensation |
$17.00
|
|
|
5 HIAA 24hr urine quant REF004069
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
2200329
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna Commercial |
$132.60
|
| Rate for Payer: First Health Commercial |
$140.40
|
| Rate for Payer: First Health Workers Compensation |
$24.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$140.40
|
| Rate for Payer: GEHA Commercial |
$109.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$140.40
|
| Rate for Payer: Multiplan All |
$141.96
|
| Rate for Payer: OMNI Networks Commercial |
$109.20
|
| Rate for Payer: One Health Plan PPO/POS |
$140.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$148.20
|
| Rate for Payer: Three Rivers Provider Network All |
$117.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$145.08
|
| Rate for Payer: Zelis Auto |
$62.40
|
| Rate for Payer: Zelis Worker's Compensation |
$17.00
|
|
|
5 HIAA plasma REF504510
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
2200328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$18.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.90
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$24.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: GEHA Medicare |
$12.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$14.19
|
| Rate for Payer: Humana Medicare Advantage |
$12.90
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$21.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.90
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.93
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$21.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$25.80
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.64
|
| Rate for Payer: United Healthcare Commercial |
$131.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.90
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.90
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Medicare |
$10.96
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$15.48
|
| Rate for Payer: Zelis Worker's Compensation |
$17.00
|
|
|
5 HIAA plasma REF504510
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
2200328
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: First Health Workers Compensation |
$24.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Worker's Compensation |
$17.00
|
|
|
5' nucleotidase REF001701
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 83915
|
| Hospital Charge Code |
2200720
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$78.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.15
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$111.35
|
| Rate for Payer: First Health Commercial |
$117.90
|
| Rate for Payer: First Health Workers Compensation |
$20.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$104.80
|
| Rate for Payer: GEHA Medicare |
$11.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Humana ChoiceCare |
$12.27
|
| Rate for Payer: Humana Medicare Advantage |
$11.15
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$18.73
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.15
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.95
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$18.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.22
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.15
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$22.30
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.93
|
| Rate for Payer: United Healthcare Commercial |
$111.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.15
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Medicare |
$9.48
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.38
|
| Rate for Payer: Zelis Worker's Compensation |
$14.53
|
|
