|
LEAD INTRAMUSCULAR GASTRIC
|
Facility
|
OP
|
$7,597.00
|
|
|
Service Code
|
CPT C1897
|
| Hospital Charge Code |
90004343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,899.25 |
| Max. Negotiated Rate |
$7,217.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,558.20
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cigna Commercial |
$6,457.45
|
| Rate for Payer: First Health Commercial |
$6,837.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,837.30
|
| Rate for Payer: GEHA Commercial |
$6,077.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,837.30
|
| Rate for Payer: Humana ChoiceCare |
$1,975.22
|
| Rate for Payer: Multiplan All |
$6,913.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,558.20
|
| Rate for Payer: OMNI Networks Commercial |
$5,317.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6,837.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,217.15
|
| Rate for Payer: Three Rivers Provider Network All |
$5,697.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,685.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,899.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,065.21
|
| Rate for Payer: Zelis Auto |
$3,038.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,798.50
|
|
|
LEAD INTRAMUSCULAR GASTRIC
|
Facility
|
IP
|
$7,597.00
|
|
|
Service Code
|
CPT C1897
|
| Hospital Charge Code |
90004343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.80 |
| Max. Negotiated Rate |
$7,217.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,077.60
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cigna Commercial |
$6,457.45
|
| Rate for Payer: First Health Commercial |
$6,837.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,837.30
|
| Rate for Payer: GEHA Commercial |
$5,317.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,837.30
|
| Rate for Payer: Multiplan All |
$6,913.27
|
| Rate for Payer: OMNI Networks Commercial |
$5,317.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6,837.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,217.15
|
| Rate for Payer: Three Rivers Provider Network All |
$5,697.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,065.21
|
| Rate for Payer: Zelis Auto |
$3,038.80
|
|
|
LEAD INTRAMUSCULAR GASTRIC
|
Facility
|
IP
|
$7,597.00
|
|
|
Service Code
|
CPT C1897
|
| Hospital Charge Code |
7002710
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.80 |
| Max. Negotiated Rate |
$7,217.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,077.60
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cash Price |
$4,558.20
|
| Rate for Payer: Cigna Commercial |
$6,457.45
|
| Rate for Payer: First Health Commercial |
$6,837.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,837.30
|
| Rate for Payer: GEHA Commercial |
$5,317.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,837.30
|
| Rate for Payer: Multiplan All |
$6,913.27
|
| Rate for Payer: OMNI Networks Commercial |
$5,317.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6,837.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,217.15
|
| Rate for Payer: Three Rivers Provider Network All |
$5,697.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,065.21
|
| Rate for Payer: Zelis Auto |
$3,038.80
|
|
|
lead urine REF007633
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2299992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.80
|
| 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 |
$21.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.11
|
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$104.80
|
| Rate for Payer: GEHA Medicare |
$12.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Humana ChoiceCare |
$13.32
|
| Rate for Payer: Humana Medicare Advantage |
$12.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.11
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.59
|
| 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 |
$20.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24.22
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.87
|
| Rate for Payer: United Healthcare Commercial |
$111.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.11
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Medicare |
$10.29
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.53
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
lead urine REF007633
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2299992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$124.45 |
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$91.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
lead whole blood (adult) REF007625
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2233656
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$124.45 |
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$91.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
lead whole blood (adult) REF007625
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2233656
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.80
|
| 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 |
$21.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.11
|
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$104.80
|
| Rate for Payer: GEHA Medicare |
$12.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Humana ChoiceCare |
$13.32
|
| Rate for Payer: Humana Medicare Advantage |
$12.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.11
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.59
|
| 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 |
$20.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24.22
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.87
|
| Rate for Payer: United Healthcare Commercial |
$111.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.11
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Medicare |
$10.29
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.53
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
lead whole blood pediatric REF717009
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2233655
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.80
|
| 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 |
$21.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.11
|
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$104.80
|
| Rate for Payer: GEHA Medicare |
$12.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Humana ChoiceCare |
$13.32
|
| Rate for Payer: Humana Medicare Advantage |
$12.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.11
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20.59
|
| 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 |
$20.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.62
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24.22
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.87
|
| Rate for Payer: United Healthcare Commercial |
$111.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.11
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Medicare |
$10.29
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.53
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
lead whole blood pediatric REF717009
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
2233655
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$124.45 |
| 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 |
$21.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$117.90
|
| Rate for Payer: GEHA Commercial |
$91.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$117.90
|
| Rate for Payer: Multiplan All |
$119.21
|
| Rate for Payer: OMNI Networks Commercial |
$91.70
|
| Rate for Payer: One Health Plan PPO/POS |
$117.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$124.45
|
| Rate for Payer: Three Rivers Provider Network All |
$98.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$121.83
|
| Rate for Payer: Zelis Auto |
$52.40
|
| Rate for Payer: Zelis Worker's Compensation |
$15.47
|
|
|
LEFLUNOMIDE 20 MG TAB
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 23155004403
|
| Hospital Charge Code |
3303025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$4.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Humana ChoiceCare |
$1.30
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3.00
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LEFLUNOMIDE 20 MG TAB
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 23155004403
|
| Hospital Charge Code |
3303025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.25
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: First Health Workers Compensation |
$1.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4.50
|
| Rate for Payer: GEHA Commercial |
$3.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4.50
|
| Rate for Payer: Multiplan All |
$4.55
|
| Rate for Payer: OMNI Networks Commercial |
$3.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4.65
|
| Rate for Payer: Zelis Auto |
$2.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1.36
|
|
|
LEFORT I-1 PIECE W/ GRAFT
|
Facility
|
OP
|
$3,273.00
|
|
|
Service Code
|
CPT 21145
|
| Hospital Charge Code |
6121145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$818.25 |
| Max. Negotiated Rate |
$3,109.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,963.80
|
| Rate for Payer: Cash Price |
$1,963.80
|
| Rate for Payer: Cigna Commercial |
$2,782.05
|
| Rate for Payer: First Health Commercial |
$2,945.70
|
| Rate for Payer: First Health Workers Compensation |
$1,263.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,945.70
|
| Rate for Payer: GEHA Commercial |
$2,618.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,945.70
|
| Rate for Payer: Humana ChoiceCare |
$850.98
|
| Rate for Payer: Multiplan All |
$2,978.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,963.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,291.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,945.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,109.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,454.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,880.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$818.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,043.89
|
| Rate for Payer: Zelis Auto |
$1,309.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,636.50
|
| Rate for Payer: Zelis Worker's Compensation |
$893.53
|
|
|
LEFORT I-1 PIECE W/ GRAFT
|
Facility
|
IP
|
$3,273.00
|
|
|
Service Code
|
CPT 21145
|
| Hospital Charge Code |
6121145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$893.53 |
| Max. Negotiated Rate |
$3,109.35 |
| Rate for Payer: Cash Price |
$1,963.80
|
| Rate for Payer: Cigna Commercial |
$2,782.05
|
| Rate for Payer: First Health Commercial |
$2,945.70
|
| Rate for Payer: First Health Workers Compensation |
$1,263.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,945.70
|
| Rate for Payer: GEHA Commercial |
$2,291.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,945.70
|
| Rate for Payer: Multiplan All |
$2,978.43
|
| Rate for Payer: OMNI Networks Commercial |
$2,291.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,945.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,109.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,454.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,043.89
|
| Rate for Payer: Zelis Auto |
$1,309.20
|
| Rate for Payer: Zelis Worker's Compensation |
$893.53
|
|
|
LEFORT I-1 PIECE W/O GRAFT
|
Facility
|
OP
|
$2,768.00
|
|
|
Service Code
|
CPT 21141
|
| Hospital Charge Code |
6121141
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$755.66 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,660.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6,630.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,660.80
|
| Rate for Payer: Cash Price |
$1,660.80
|
| Rate for Payer: Cigna Commercial |
$2,352.80
|
| Rate for Payer: First Health Commercial |
$2,491.20
|
| Rate for Payer: First Health Workers Compensation |
$1,068.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,491.20
|
| Rate for Payer: GEHA Commercial |
$2,214.40
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,491.20
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6,765.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,518.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,937.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,491.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7,811.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6,765.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,629.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$2,076.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,765.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,574.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,107.20
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$755.66
|
|
|
LEFORT I-1 PIECE W/O GRAFT
|
Facility
|
IP
|
$2,768.00
|
|
|
Service Code
|
CPT 21141
|
| Hospital Charge Code |
6121141
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$755.66 |
| Max. Negotiated Rate |
$2,629.60 |
| Rate for Payer: Cash Price |
$1,660.80
|
| Rate for Payer: Cigna Commercial |
$2,352.80
|
| Rate for Payer: First Health Commercial |
$2,491.20
|
| Rate for Payer: First Health Workers Compensation |
$1,068.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,491.20
|
| Rate for Payer: GEHA Commercial |
$1,937.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,491.20
|
| Rate for Payer: Multiplan All |
$2,518.88
|
| Rate for Payer: OMNI Networks Commercial |
$1,937.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,491.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,629.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,076.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,574.24
|
| Rate for Payer: Zelis Auto |
$1,107.20
|
| Rate for Payer: Zelis Worker's Compensation |
$755.66
|
|
|
LEFORT I-2 PIECE W/ GRAFT
|
Facility
|
IP
|
$3,202.00
|
|
|
Service Code
|
CPT 21146
|
| Hospital Charge Code |
6121146
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$874.15 |
| Max. Negotiated Rate |
$3,041.90 |
| Rate for Payer: Cash Price |
$1,921.20
|
| Rate for Payer: Cigna Commercial |
$2,721.70
|
| Rate for Payer: First Health Commercial |
$2,881.80
|
| Rate for Payer: First Health Workers Compensation |
$1,236.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,881.80
|
| Rate for Payer: GEHA Commercial |
$2,241.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,881.80
|
| Rate for Payer: Multiplan All |
$2,913.82
|
| Rate for Payer: OMNI Networks Commercial |
$2,241.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,881.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,041.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,401.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,977.86
|
| Rate for Payer: Zelis Auto |
$1,280.80
|
| Rate for Payer: Zelis Worker's Compensation |
$874.15
|
|
|
LEFORT I-2 PIECE W/ GRAFT
|
Facility
|
OP
|
$3,202.00
|
|
|
Service Code
|
CPT 21146
|
| Hospital Charge Code |
6121146
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$800.50 |
| Max. Negotiated Rate |
$3,041.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,921.20
|
| Rate for Payer: Cash Price |
$1,921.20
|
| Rate for Payer: Cigna Commercial |
$2,721.70
|
| Rate for Payer: First Health Commercial |
$2,881.80
|
| Rate for Payer: First Health Workers Compensation |
$1,236.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,881.80
|
| Rate for Payer: GEHA Commercial |
$2,561.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,881.80
|
| Rate for Payer: Humana ChoiceCare |
$832.52
|
| Rate for Payer: Multiplan All |
$2,913.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,921.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,241.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,881.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,041.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,401.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,817.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$800.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,977.86
|
| Rate for Payer: Zelis Auto |
$1,280.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,601.00
|
| Rate for Payer: Zelis Worker's Compensation |
$874.15
|
|
|
LEFORT I-2 PIECE W/O GRAFT
|
Facility
|
OP
|
$2,902.00
|
|
|
Service Code
|
CPT 21142
|
| Hospital Charge Code |
6121142
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$792.25 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,741.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6,630.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,741.20
|
| Rate for Payer: Cash Price |
$1,741.20
|
| Rate for Payer: Cigna Commercial |
$2,466.70
|
| Rate for Payer: First Health Commercial |
$2,611.80
|
| Rate for Payer: First Health Workers Compensation |
$1,120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,611.80
|
| Rate for Payer: GEHA Commercial |
$2,321.60
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,611.80
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6,765.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,640.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$2,031.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,611.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7,811.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6,765.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,756.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$2,176.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,765.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,698.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,160.80
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$792.25
|
|
|
LEFORT I-2 PIECE W/O GRAFT
|
Facility
|
IP
|
$2,902.00
|
|
|
Service Code
|
CPT 21142
|
| Hospital Charge Code |
6121142
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$792.25 |
| Max. Negotiated Rate |
$2,756.90 |
| Rate for Payer: Cash Price |
$1,741.20
|
| Rate for Payer: Cigna Commercial |
$2,466.70
|
| Rate for Payer: First Health Commercial |
$2,611.80
|
| Rate for Payer: First Health Workers Compensation |
$1,120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,611.80
|
| Rate for Payer: GEHA Commercial |
$2,031.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,611.80
|
| Rate for Payer: Multiplan All |
$2,640.82
|
| Rate for Payer: OMNI Networks Commercial |
$2,031.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,611.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,756.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,176.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,698.86
|
| Rate for Payer: Zelis Auto |
$1,160.80
|
| Rate for Payer: Zelis Worker's Compensation |
$792.25
|
|
|
LEFORT I-3/> PIECE W/ GRAFT
|
Facility
|
OP
|
$3,615.00
|
|
|
Service Code
|
CPT 21147
|
| Hospital Charge Code |
6121147
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$903.75 |
| Max. Negotiated Rate |
$3,434.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,169.00
|
| Rate for Payer: Cash Price |
$2,169.00
|
| Rate for Payer: Cigna Commercial |
$3,072.75
|
| Rate for Payer: First Health Commercial |
$3,253.50
|
| Rate for Payer: First Health Workers Compensation |
$1,395.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,253.50
|
| Rate for Payer: GEHA Commercial |
$2,892.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,253.50
|
| Rate for Payer: Humana ChoiceCare |
$939.90
|
| Rate for Payer: Multiplan All |
$3,289.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,169.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,530.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,253.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,434.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,711.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,181.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$903.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,361.95
|
| Rate for Payer: Zelis Auto |
$1,446.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,807.50
|
| Rate for Payer: Zelis Worker's Compensation |
$986.89
|
|
|
LEFORT I-3/> PIECE W/ GRAFT
|
Facility
|
IP
|
$3,615.00
|
|
|
Service Code
|
CPT 21147
|
| Hospital Charge Code |
6121147
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$986.89 |
| Max. Negotiated Rate |
$3,434.25 |
| Rate for Payer: Cash Price |
$2,169.00
|
| Rate for Payer: Cigna Commercial |
$3,072.75
|
| Rate for Payer: First Health Commercial |
$3,253.50
|
| Rate for Payer: First Health Workers Compensation |
$1,395.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,253.50
|
| Rate for Payer: GEHA Commercial |
$2,530.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,253.50
|
| Rate for Payer: Multiplan All |
$3,289.65
|
| Rate for Payer: OMNI Networks Commercial |
$2,530.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,253.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,434.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,711.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,361.95
|
| Rate for Payer: Zelis Auto |
$1,446.00
|
| Rate for Payer: Zelis Worker's Compensation |
$986.89
|
|
|
LEFORT I-3/> PIECE W/O GRAFT
|
Facility
|
OP
|
$2,921.00
|
|
|
Service Code
|
CPT 21143
|
| Hospital Charge Code |
6121143
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$797.43 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,752.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$8,369.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$6,630.37
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$1,752.60
|
| Rate for Payer: Cash Price |
$1,752.60
|
| Rate for Payer: Cigna Commercial |
$2,482.85
|
| Rate for Payer: First Health Commercial |
$2,628.90
|
| Rate for Payer: First Health Workers Compensation |
$1,127.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,628.90
|
| Rate for Payer: GEHA Commercial |
$2,336.80
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,628.90
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$6,765.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$2,658.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$2,044.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,628.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$7,811.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$6,765.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,774.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$2,190.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,765.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,716.53
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,168.40
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$797.43
|
|
|
LEFORT I-3/> PIECE W/O GRAFT
|
Facility
|
IP
|
$2,921.00
|
|
|
Service Code
|
CPT 21143
|
| Hospital Charge Code |
6121143
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$797.43 |
| Max. Negotiated Rate |
$2,774.95 |
| Rate for Payer: Cash Price |
$1,752.60
|
| Rate for Payer: Cigna Commercial |
$2,482.85
|
| Rate for Payer: First Health Commercial |
$2,628.90
|
| Rate for Payer: First Health Workers Compensation |
$1,127.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,628.90
|
| Rate for Payer: GEHA Commercial |
$2,044.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,628.90
|
| Rate for Payer: Multiplan All |
$2,658.11
|
| Rate for Payer: OMNI Networks Commercial |
$2,044.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,628.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,774.95
|
| Rate for Payer: Three Rivers Provider Network All |
$2,190.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,716.53
|
| Rate for Payer: Zelis Auto |
$1,168.40
|
| Rate for Payer: Zelis Worker's Compensation |
$797.43
|
|
|
LEFORT II ANTERIOR INTRUSION
|
Facility
|
OP
|
$3,468.00
|
|
|
Service Code
|
CPT 21150
|
| Hospital Charge Code |
6121150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$946.76 |
| Max. Negotiated Rate |
$11,234.32 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,080.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,345.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,442.85
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5,617.16
|
| Rate for Payer: Cash Price |
$2,080.80
|
| Rate for Payer: Cash Price |
$2,080.80
|
| Rate for Payer: Cigna Commercial |
$2,947.80
|
| Rate for Payer: First Health Commercial |
$3,121.20
|
| Rate for Payer: First Health Workers Compensation |
$1,338.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,121.20
|
| Rate for Payer: GEHA Commercial |
$2,774.40
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,121.20
|
| Rate for Payer: Humana ChoiceCare |
$6,178.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,617.16
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$9,436.83
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,512.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5,617.16
|
| Rate for Payer: Multiplan All |
$3,155.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$2,427.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,121.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,056.21
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,512.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5,617.16
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,294.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$2,601.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,504.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,512.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,617.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,225.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,387.20
|
| Rate for Payer: Zelis Medicare |
$4,774.59
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,740.59
|
| Rate for Payer: Zelis Worker's Compensation |
$946.76
|
|
|
LEFORT II ANTERIOR INTRUSION
|
Facility
|
IP
|
$3,468.00
|
|
|
Service Code
|
CPT 21150
|
| Hospital Charge Code |
6121150
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$946.76 |
| Max. Negotiated Rate |
$3,294.60 |
| Rate for Payer: Cash Price |
$2,080.80
|
| Rate for Payer: Cigna Commercial |
$2,947.80
|
| Rate for Payer: First Health Commercial |
$3,121.20
|
| Rate for Payer: First Health Workers Compensation |
$1,338.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,121.20
|
| Rate for Payer: GEHA Commercial |
$2,427.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,121.20
|
| Rate for Payer: Multiplan All |
$3,155.88
|
| Rate for Payer: OMNI Networks Commercial |
$2,427.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,121.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,294.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,601.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,225.24
|
| Rate for Payer: Zelis Auto |
$1,387.20
|
| Rate for Payer: Zelis Worker's Compensation |
$946.76
|
|
