|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$2,134.00
|
|
|
Service Code
|
CPT 69601
|
| Hospital Charge Code |
6169601
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$582.58 |
| 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 |
$1,280.40
|
| 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 |
$1,280.40
|
| Rate for Payer: Cash Price |
$1,280.40
|
| Rate for Payer: Cigna Commercial |
$1,813.90
|
| Rate for Payer: First Health Commercial |
$1,920.60
|
| Rate for Payer: First Health Workers Compensation |
$823.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,920.60
|
| Rate for Payer: GEHA Commercial |
$1,707.20
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,920.60
|
| 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 |
$1,941.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,493.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,920.60
|
| 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 |
$2,027.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,600.50
|
| 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 |
$1,984.62
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$853.60
|
| 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 |
$582.58
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$3,171.00
|
|
|
Service Code
|
CPT 69605
|
| Hospital Charge Code |
6169605
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$792.75 |
| Max. Negotiated Rate |
$3,012.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,902.60
|
| Rate for Payer: Cash Price |
$1,902.60
|
| Rate for Payer: Cigna Commercial |
$2,695.35
|
| Rate for Payer: First Health Commercial |
$2,853.90
|
| Rate for Payer: First Health Workers Compensation |
$1,224.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,853.90
|
| Rate for Payer: GEHA Commercial |
$2,536.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,853.90
|
| Rate for Payer: Humana ChoiceCare |
$824.46
|
| Rate for Payer: Multiplan All |
$2,885.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,902.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,219.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,853.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,012.45
|
| Rate for Payer: Three Rivers Provider Network All |
$2,378.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,790.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$792.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,949.03
|
| Rate for Payer: Zelis Auto |
$1,268.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,585.50
|
| Rate for Payer: Zelis Worker's Compensation |
$865.68
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$2,268.00
|
|
|
Service Code
|
CPT 69604
|
| Hospital Charge Code |
6169604
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$619.16 |
| 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 |
$1,360.80
|
| 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 |
$1,360.80
|
| Rate for Payer: Cash Price |
$1,360.80
|
| Rate for Payer: Cigna Commercial |
$1,927.80
|
| Rate for Payer: First Health Commercial |
$2,041.20
|
| Rate for Payer: First Health Workers Compensation |
$875.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,041.20
|
| Rate for Payer: GEHA Commercial |
$1,814.40
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,041.20
|
| 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 |
$2,063.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,587.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,041.20
|
| 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 |
$2,154.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,701.00
|
| 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 |
$2,109.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$907.20
|
| 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 |
$619.16
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
IP
|
$3,171.00
|
|
|
Service Code
|
CPT 69605
|
| Hospital Charge Code |
6169605
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$865.68 |
| Max. Negotiated Rate |
$3,012.45 |
| Rate for Payer: Cash Price |
$1,902.60
|
| Rate for Payer: Cigna Commercial |
$2,695.35
|
| Rate for Payer: First Health Commercial |
$2,853.90
|
| Rate for Payer: First Health Workers Compensation |
$1,224.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,853.90
|
| Rate for Payer: GEHA Commercial |
$2,219.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,853.90
|
| Rate for Payer: Multiplan All |
$2,885.61
|
| Rate for Payer: OMNI Networks Commercial |
$2,219.70
|
| Rate for Payer: One Health Plan PPO/POS |
$2,853.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,012.45
|
| Rate for Payer: Three Rivers Provider Network All |
$2,378.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,949.03
|
| Rate for Payer: Zelis Auto |
$1,268.40
|
| Rate for Payer: Zelis Worker's Compensation |
$865.68
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
IP
|
$2,580.00
|
|
|
Service Code
|
CPT 69603
|
| Hospital Charge Code |
6169603
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$704.34 |
| Max. Negotiated Rate |
$2,451.00 |
| Rate for Payer: Cash Price |
$1,548.00
|
| Rate for Payer: Cigna Commercial |
$2,193.00
|
| Rate for Payer: First Health Commercial |
$2,322.00
|
| Rate for Payer: First Health Workers Compensation |
$996.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,322.00
|
| Rate for Payer: GEHA Commercial |
$1,806.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,322.00
|
| Rate for Payer: Multiplan All |
$2,347.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,806.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,322.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,451.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,935.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,399.40
|
| Rate for Payer: Zelis Auto |
$1,032.00
|
| Rate for Payer: Zelis Worker's Compensation |
$704.34
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$2,580.00
|
|
|
Service Code
|
CPT 69603
|
| Hospital Charge Code |
6169603
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$704.34 |
| 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 |
$1,548.00
|
| 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 |
$1,548.00
|
| Rate for Payer: Cash Price |
$1,548.00
|
| Rate for Payer: Cigna Commercial |
$2,193.00
|
| Rate for Payer: First Health Commercial |
$2,322.00
|
| Rate for Payer: First Health Workers Compensation |
$996.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,322.00
|
| Rate for Payer: GEHA Commercial |
$2,064.00
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,322.00
|
| 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 |
$2,347.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,806.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,322.00
|
| 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 |
$2,451.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$1,935.00
|
| 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 |
$2,399.40
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$1,032.00
|
| 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 |
$704.34
|
|
|
MAST RADICAL
|
Facility
|
IP
|
$2,347.00
|
|
|
Service Code
|
CPT 19305
|
| Hospital Charge Code |
6119305
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$640.73 |
| Max. Negotiated Rate |
$2,229.65 |
| Rate for Payer: Cash Price |
$1,408.20
|
| Rate for Payer: Cigna Commercial |
$1,994.95
|
| Rate for Payer: First Health Commercial |
$2,112.30
|
| Rate for Payer: First Health Workers Compensation |
$906.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,112.30
|
| Rate for Payer: GEHA Commercial |
$1,642.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,112.30
|
| Rate for Payer: Multiplan All |
$2,135.77
|
| Rate for Payer: OMNI Networks Commercial |
$1,642.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,112.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,229.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,760.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,182.71
|
| Rate for Payer: Zelis Auto |
$938.80
|
| Rate for Payer: Zelis Worker's Compensation |
$640.73
|
|
|
MAST RADICAL
|
Facility
|
OP
|
$2,347.00
|
|
|
Service Code
|
CPT 19305
|
| Hospital Charge Code |
6119305
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$586.75 |
| Max. Negotiated Rate |
$2,229.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,408.20
|
| Rate for Payer: Cash Price |
$1,408.20
|
| Rate for Payer: Cigna Commercial |
$1,994.95
|
| Rate for Payer: First Health Commercial |
$2,112.30
|
| Rate for Payer: First Health Workers Compensation |
$906.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,112.30
|
| Rate for Payer: GEHA Commercial |
$1,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,112.30
|
| Rate for Payer: Humana ChoiceCare |
$610.22
|
| Rate for Payer: Multiplan All |
$2,135.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,408.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,642.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,112.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,229.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,760.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,065.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$586.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,182.71
|
| Rate for Payer: Zelis Auto |
$938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,173.50
|
| Rate for Payer: Zelis Worker's Compensation |
$640.73
|
|
|
MAST RAD URBAN TYPE
|
Facility
|
OP
|
$2,494.00
|
|
|
Service Code
|
CPT 19306
|
| Hospital Charge Code |
6119306
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$623.50 |
| Max. Negotiated Rate |
$2,369.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,496.40
|
| Rate for Payer: Cash Price |
$1,496.40
|
| Rate for Payer: Cigna Commercial |
$2,119.90
|
| Rate for Payer: First Health Commercial |
$2,244.60
|
| Rate for Payer: First Health Workers Compensation |
$962.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,244.60
|
| Rate for Payer: GEHA Commercial |
$1,995.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,244.60
|
| Rate for Payer: Humana ChoiceCare |
$648.44
|
| Rate for Payer: Multiplan All |
$2,269.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,496.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,745.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,244.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,369.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,870.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,194.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$623.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,319.42
|
| Rate for Payer: Zelis Auto |
$997.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,247.00
|
| Rate for Payer: Zelis Worker's Compensation |
$680.86
|
|
|
MAST RAD URBAN TYPE
|
Facility
|
IP
|
$2,494.00
|
|
|
Service Code
|
CPT 19306
|
| Hospital Charge Code |
6119306
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$680.86 |
| Max. Negotiated Rate |
$2,369.30 |
| Rate for Payer: Cash Price |
$1,496.40
|
| Rate for Payer: Cigna Commercial |
$2,119.90
|
| Rate for Payer: First Health Commercial |
$2,244.60
|
| Rate for Payer: First Health Workers Compensation |
$962.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,244.60
|
| Rate for Payer: GEHA Commercial |
$1,745.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,244.60
|
| Rate for Payer: Multiplan All |
$2,269.54
|
| Rate for Payer: OMNI Networks Commercial |
$1,745.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,244.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,369.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,870.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,319.42
|
| Rate for Payer: Zelis Auto |
$997.60
|
| Rate for Payer: Zelis Worker's Compensation |
$680.86
|
|
|
MAST SIMPLE COMPLETE
|
Facility
|
IP
|
$2,106.00
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
6119303
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$574.94 |
| Max. Negotiated Rate |
$2,000.70 |
| Rate for Payer: Cash Price |
$1,263.60
|
| Rate for Payer: Cigna Commercial |
$1,790.10
|
| Rate for Payer: First Health Commercial |
$1,895.40
|
| Rate for Payer: First Health Workers Compensation |
$813.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,895.40
|
| Rate for Payer: GEHA Commercial |
$1,474.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,895.40
|
| Rate for Payer: Multiplan All |
$1,916.46
|
| Rate for Payer: OMNI Networks Commercial |
$1,474.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,895.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,000.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,579.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,958.58
|
| Rate for Payer: Zelis Auto |
$842.40
|
| Rate for Payer: Zelis Worker's Compensation |
$574.94
|
|
|
MAST SIMPLE COMPLETE
|
Facility
|
OP
|
$2,106.00
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
6119303
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$574.94 |
| Max. Negotiated Rate |
$12,384.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,454.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,263.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,454.43
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,736.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,192.39
|
| Rate for Payer: Cash Price |
$1,263.60
|
| Rate for Payer: Cash Price |
$1,263.60
|
| Rate for Payer: Cigna Commercial |
$1,790.10
|
| Rate for Payer: First Health Commercial |
$1,895.40
|
| Rate for Payer: First Health Workers Compensation |
$813.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,895.40
|
| Rate for Payer: GEHA Commercial |
$1,684.80
|
| Rate for Payer: GEHA Medicare |
$6,192.39
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,895.40
|
| Rate for Payer: Humana ChoiceCare |
$6,811.63
|
| Rate for Payer: Humana Medicare Advantage |
$6,192.39
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10,403.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,792.33
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,192.39
|
| Rate for Payer: Multiplan All |
$1,916.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,527.06
|
| Rate for Payer: OMNI Networks Commercial |
$1,474.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,895.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,224.13
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,792.33
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,192.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$12,384.78
|
| Rate for Payer: Three Rivers Provider Network All |
$1,579.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,068.54
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,792.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,192.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,958.58
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,192.39
|
| Rate for Payer: Zelis Auto |
$842.40
|
| Rate for Payer: Zelis Medicare |
$5,263.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,430.87
|
| Rate for Payer: Zelis Worker's Compensation |
$574.94
|
|
|
MAXILLOFACIAL FIXATION
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
CPT 21100
|
| Hospital Charge Code |
6121100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$278.46 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna Commercial |
$867.00
|
| Rate for Payer: First Health Commercial |
$918.00
|
| Rate for Payer: First Health Workers Compensation |
$393.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$918.00
|
| Rate for Payer: GEHA Commercial |
$714.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$918.00
|
| Rate for Payer: Multiplan All |
$928.20
|
| Rate for Payer: OMNI Networks Commercial |
$714.00
|
| Rate for Payer: One Health Plan PPO/POS |
$918.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$969.00
|
| Rate for Payer: Three Rivers Provider Network All |
$765.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$948.60
|
| Rate for Payer: Zelis Auto |
$408.00
|
| Rate for Payer: Zelis Worker's Compensation |
$278.46
|
|
|
MAXILLOFACIAL FIXATION
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
CPT 21100
|
| Hospital Charge Code |
6121100
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$278.46 |
| 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 |
$612.00
|
| 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 |
$612.00
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna Commercial |
$867.00
|
| Rate for Payer: First Health Commercial |
$918.00
|
| Rate for Payer: First Health Workers Compensation |
$393.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$918.00
|
| Rate for Payer: GEHA Commercial |
$816.00
|
| Rate for Payer: GEHA Medicare |
$5,617.16
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$918.00
|
| 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 |
$928.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,549.17
|
| Rate for Payer: OMNI Networks Commercial |
$714.00
|
| Rate for Payer: One Health Plan PPO/POS |
$918.00
|
| 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 |
$969.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$11,234.32
|
| Rate for Payer: Three Rivers Provider Network All |
$765.00
|
| 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 |
$948.60
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5,617.16
|
| Rate for Payer: Zelis Auto |
$408.00
|
| 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 |
$278.46
|
|
|
MAXIMUM BREATHING CAPACITY
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
4094200
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$47.94 |
| Max. Negotiated Rate |
$326.80 |
| 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 |
$206.40
|
| 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 |
$56.40
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cigna Commercial |
$292.40
|
| Rate for Payer: First Health Commercial |
$309.60
|
| Rate for Payer: First Health Workers Compensation |
$132.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$309.60
|
| Rate for Payer: GEHA Commercial |
$275.20
|
| Rate for Payer: GEHA Medicare |
$56.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$309.60
|
| Rate for Payer: Humana ChoiceCare |
$62.04
|
| Rate for Payer: Humana Medicare Advantage |
$56.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$94.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$159.67
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$56.40
|
| Rate for Payer: Multiplan All |
$313.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$95.88
|
| Rate for Payer: OMNI Networks Commercial |
$240.80
|
| Rate for Payer: One Health Plan PPO/POS |
$309.60
|
| 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 |
$56.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$326.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$112.80
|
| Rate for Payer: Three Rivers Provider Network All |
$258.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.27
|
| Rate for Payer: United Healthcare Commercial |
$292.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$159.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$319.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$56.40
|
| Rate for Payer: Zelis Auto |
$137.60
|
| Rate for Payer: Zelis Medicare |
$47.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$67.68
|
| Rate for Payer: Zelis Worker's Compensation |
$93.91
|
|
|
MAXIMUM BREATHING CAPACITY
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
4094200
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$93.91 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cigna Commercial |
$292.40
|
| Rate for Payer: First Health Commercial |
$309.60
|
| Rate for Payer: First Health Workers Compensation |
$132.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$309.60
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$309.60
|
| Rate for Payer: Multiplan All |
$313.04
|
| Rate for Payer: OMNI Networks Commercial |
$240.80
|
| Rate for Payer: One Health Plan PPO/POS |
$309.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$326.80
|
| Rate for Payer: Three Rivers Provider Network All |
$258.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$319.92
|
| Rate for Payer: Zelis Auto |
$137.60
|
| Rate for Payer: Zelis Worker's Compensation |
$93.91
|
|
|
MDI INITIAL TX
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4020029
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI INITIAL TX
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4020029
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI SECOND MED SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090005
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI SECOND MED SUBSEQUENT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090005
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI SPACER
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000710
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
MDI SPACER
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000710
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
MDI SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090004
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI SUBSEQUENT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090004
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
MDI THIRD MED SUBSEQUENT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
4090006
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$386.26 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$246.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$195.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$193.13
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$193.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$212.44
|
| Rate for Payer: Humana Medicare Advantage |
$193.13
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$324.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$199.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$193.13
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.32
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$230.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$199.53
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$193.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$386.26
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$189.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$199.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$193.13
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$164.16
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$231.76
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
