|
MM MAMMO 3D IMPLANTS SCR COMBO HD
|
Facility
|
OP
|
$299.00
|
|
|
Service Code
|
CPT 77063
|
| Hospital Charge Code |
2766920
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$284.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$35.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$179.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$35.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.21
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$65.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$239.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Humana ChoiceCare |
$77.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.78
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$179.40
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.24
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$263.12
|
| Rate for Payer: United Healthcare Commercial |
$254.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$149.50
|
| Rate for Payer: Zelis Worker's Compensation |
$46.31
|
|
|
MM MAMMO 3D IMPLANTS SCR COMBO HD
|
Facility
|
IP
|
$299.00
|
|
|
Service Code
|
CPT 77063
|
| Hospital Charge Code |
2766920
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$46.31 |
| Max. Negotiated Rate |
$284.05 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$254.15
|
| Rate for Payer: First Health Commercial |
$269.10
|
| Rate for Payer: First Health Workers Compensation |
$65.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$269.10
|
| Rate for Payer: GEHA Commercial |
$209.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$269.10
|
| Rate for Payer: Multiplan All |
$272.09
|
| Rate for Payer: OMNI Networks Commercial |
$209.30
|
| Rate for Payer: One Health Plan PPO/POS |
$269.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$284.05
|
| Rate for Payer: Three Rivers Provider Network All |
$224.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$278.07
|
| Rate for Payer: Zelis Auto |
$119.60
|
| Rate for Payer: Zelis Worker's Compensation |
$46.31
|
|
|
MM MAMMO-DIAG-BILAT
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
2700235
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$144.68 |
| Max. Negotiated Rate |
$659.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$237.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$416.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$237.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$188.45
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$204.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$555.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Humana ChoiceCare |
$180.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$192.29
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$416.40
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$222.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$192.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$610.72
|
| Rate for Payer: United Healthcare Commercial |
$589.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$192.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$347.00
|
| Rate for Payer: Zelis Worker's Compensation |
$144.68
|
|
|
MM MAMMO-DIAG-BILAT
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
2700235
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$144.68 |
| Max. Negotiated Rate |
$659.30 |
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$204.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$485.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Worker's Compensation |
$144.68
|
|
|
MM MAMMO-DIAG-UNILAT
|
Facility
|
IP
|
$542.00
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
2700075
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$114.48 |
| Max. Negotiated Rate |
$514.90 |
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$460.70
|
| Rate for Payer: First Health Commercial |
$487.80
|
| Rate for Payer: First Health Workers Compensation |
$161.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$487.80
|
| Rate for Payer: GEHA Commercial |
$379.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$487.80
|
| Rate for Payer: Multiplan All |
$493.22
|
| Rate for Payer: OMNI Networks Commercial |
$379.40
|
| Rate for Payer: One Health Plan PPO/POS |
$487.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$514.90
|
| Rate for Payer: Three Rivers Provider Network All |
$406.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$504.06
|
| Rate for Payer: Zelis Auto |
$216.80
|
| Rate for Payer: Zelis Worker's Compensation |
$114.48
|
|
|
MM MAMMO-DIAG-UNILAT
|
Facility
|
OP
|
$542.00
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
2700075
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$114.48 |
| Max. Negotiated Rate |
$514.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$188.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$325.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$188.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$149.24
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$460.70
|
| Rate for Payer: First Health Commercial |
$487.80
|
| Rate for Payer: First Health Workers Compensation |
$161.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$487.80
|
| Rate for Payer: GEHA Commercial |
$433.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$487.80
|
| Rate for Payer: Humana ChoiceCare |
$140.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$152.28
|
| Rate for Payer: Multiplan All |
$493.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$325.20
|
| Rate for Payer: OMNI Networks Commercial |
$379.40
|
| Rate for Payer: One Health Plan PPO/POS |
$487.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$175.83
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$152.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$514.90
|
| Rate for Payer: Three Rivers Provider Network All |
$406.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$460.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$152.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$504.06
|
| Rate for Payer: Zelis Auto |
$216.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$271.00
|
| Rate for Payer: Zelis Worker's Compensation |
$114.48
|
|
|
MM MAMMO IMPLANTS DX CONVENTIONAL
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
2766915
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$144.68 |
| Max. Negotiated Rate |
$659.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$237.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$416.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$237.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$188.45
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$204.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$555.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Humana ChoiceCare |
$180.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$192.29
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$416.40
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$222.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$192.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$610.72
|
| Rate for Payer: United Healthcare Commercial |
$589.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$192.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$347.00
|
| Rate for Payer: Zelis Worker's Compensation |
$144.68
|
|
|
MM MAMMO IMPLANTS DX CONVENTIONAL
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
2766915
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$144.68 |
| Max. Negotiated Rate |
$659.30 |
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cigna Commercial |
$589.90
|
| Rate for Payer: First Health Commercial |
$624.60
|
| Rate for Payer: First Health Workers Compensation |
$204.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$624.60
|
| Rate for Payer: GEHA Commercial |
$485.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$624.60
|
| Rate for Payer: Multiplan All |
$631.54
|
| Rate for Payer: OMNI Networks Commercial |
$485.80
|
| Rate for Payer: One Health Plan PPO/POS |
$624.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$659.30
|
| Rate for Payer: Three Rivers Provider Network All |
$520.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$645.42
|
| Rate for Payer: Zelis Auto |
$277.60
|
| Rate for Payer: Zelis Worker's Compensation |
$144.68
|
|
|
MM MAMMO IMPLANTS SCR CONVENTIONAL
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
2766914
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$116.58 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$164.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$332.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$116.58
|
|
|
MM MAMMO IMPLANTS SCR CONVENTIONAL
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
2766914
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$116.58 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$191.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$285.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$191.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$151.64
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$164.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$380.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Humana ChoiceCare |
$123.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$154.73
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$285.00
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$178.65
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$154.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$418.00
|
| Rate for Payer: United Healthcare Commercial |
$403.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$237.50
|
| Rate for Payer: Zelis Worker's Compensation |
$116.58
|
|
|
MMR VACCINE, SC
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
9100003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$61.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$55.25
|
| Rate for Payer: First Health Commercial |
$58.50
|
| Rate for Payer: First Health Workers Compensation |
$25.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.50
|
| Rate for Payer: GEHA Commercial |
$52.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.50
|
| Rate for Payer: Humana ChoiceCare |
$16.90
|
| Rate for Payer: Multiplan All |
$59.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.00
|
| Rate for Payer: OMNI Networks Commercial |
$45.50
|
| Rate for Payer: One Health Plan PPO/POS |
$58.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$61.75
|
| Rate for Payer: Three Rivers Provider Network All |
$48.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$57.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.45
|
| Rate for Payer: Zelis Auto |
$26.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$32.50
|
| Rate for Payer: Zelis Worker's Compensation |
$17.75
|
|
|
MMR VACCINE, SC
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
CPT 90707
|
| Hospital Charge Code |
9100003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.75 |
| Max. Negotiated Rate |
$61.75 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$55.25
|
| Rate for Payer: First Health Commercial |
$58.50
|
| Rate for Payer: First Health Workers Compensation |
$25.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$58.50
|
| Rate for Payer: GEHA Commercial |
$45.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$58.50
|
| Rate for Payer: Multiplan All |
$59.15
|
| Rate for Payer: OMNI Networks Commercial |
$45.50
|
| Rate for Payer: One Health Plan PPO/POS |
$58.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$61.75
|
| Rate for Payer: Three Rivers Provider Network All |
$48.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$60.45
|
| Rate for Payer: Zelis Auto |
$26.00
|
| Rate for Payer: Zelis Worker's Compensation |
$17.75
|
|
|
MMRV VACCINE, SC
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
9400048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
MMRV VACCINE, SC
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
9400048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
MM SCREEN DIG MAMO ALL
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
2760083
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$116.58 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$191.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$285.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$191.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$151.64
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$164.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$380.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Humana ChoiceCare |
$123.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$154.73
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$285.00
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$178.65
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$154.73
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$418.00
|
| Rate for Payer: United Healthcare Commercial |
$403.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.73
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$237.50
|
| Rate for Payer: Zelis Worker's Compensation |
$116.58
|
|
|
MM SCREEN DIG MAMO ALL
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
2760083
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$116.58 |
| Max. Negotiated Rate |
$451.25 |
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$403.75
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: First Health Workers Compensation |
$164.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$427.50
|
| Rate for Payer: GEHA Commercial |
$332.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$427.50
|
| Rate for Payer: Multiplan All |
$432.25
|
| Rate for Payer: OMNI Networks Commercial |
$332.50
|
| Rate for Payer: One Health Plan PPO/POS |
$427.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$451.25
|
| Rate for Payer: Three Rivers Provider Network All |
$356.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$441.75
|
| Rate for Payer: Zelis Auto |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$116.58
|
|
|
MNPJ OF TMJ W/ANESTH
|
Facility
|
IP
|
$653.00
|
|
|
Service Code
|
CPT 21073
|
| Hospital Charge Code |
6121073
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$178.27 |
| Max. Negotiated Rate |
$620.35 |
| Rate for Payer: Cash Price |
$391.80
|
| Rate for Payer: Cigna Commercial |
$555.05
|
| Rate for Payer: First Health Commercial |
$587.70
|
| Rate for Payer: First Health Workers Compensation |
$252.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$587.70
|
| Rate for Payer: GEHA Commercial |
$457.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$587.70
|
| Rate for Payer: Multiplan All |
$594.23
|
| Rate for Payer: OMNI Networks Commercial |
$457.10
|
| Rate for Payer: One Health Plan PPO/POS |
$587.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$620.35
|
| Rate for Payer: Three Rivers Provider Network All |
$489.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$607.29
|
| Rate for Payer: Zelis Auto |
$261.20
|
| Rate for Payer: Zelis Worker's Compensation |
$178.27
|
|
|
MNPJ OF TMJ W/ANESTH
|
Facility
|
OP
|
$653.00
|
|
|
Service Code
|
CPT 21073
|
| Hospital Charge Code |
6121073
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$178.27 |
| Max. Negotiated Rate |
$2,813.06 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$391.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$770.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,406.53
|
| Rate for Payer: Cash Price |
$391.80
|
| Rate for Payer: Cash Price |
$391.80
|
| Rate for Payer: Cigna Commercial |
$555.05
|
| Rate for Payer: First Health Commercial |
$587.70
|
| Rate for Payer: First Health Workers Compensation |
$252.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$587.70
|
| Rate for Payer: GEHA Commercial |
$522.40
|
| Rate for Payer: GEHA Medicare |
$1,406.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$587.70
|
| Rate for Payer: Humana ChoiceCare |
$1,547.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,406.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,362.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$622.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,406.53
|
| Rate for Payer: Multiplan All |
$594.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,391.10
|
| Rate for Payer: OMNI Networks Commercial |
$457.10
|
| Rate for Payer: One Health Plan PPO/POS |
$587.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$719.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$622.75
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,406.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$620.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$2,813.06
|
| Rate for Payer: Three Rivers Provider Network All |
$489.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,378.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$622.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,406.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$607.29
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,406.53
|
| Rate for Payer: Zelis Auto |
$261.20
|
| Rate for Payer: Zelis Medicare |
$1,195.55
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,687.84
|
| Rate for Payer: Zelis Worker's Compensation |
$178.27
|
|
|
MNT-GROUP 30 MINS
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 97804
|
| Hospital Charge Code |
2050002
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$35.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$35.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.00
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$12.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.57
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29.40
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$32.98
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.57
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$41.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.57
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24.50
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
MNT-GROUP 30 MINS
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 97804
|
| Hospital Charge Code |
2050002
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
MNT-INITIAL 15 MINS
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 97802
|
| Hospital Charge Code |
2050000
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$76.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$76.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$60.77
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$85.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$62.01
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.20
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$71.60
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$62.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$94.16
|
| Rate for Payer: United Healthcare Commercial |
$90.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.50
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
MNT-INITIAL 15 MINS
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 97802
|
| Hospital Charge Code |
2050000
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$74.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
MNT-RE-ASSESS 15 MIN
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT 97803
|
| Hospital Charge Code |
2050001
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$23.66 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$66.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$66.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.91
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.99
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$62.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.99
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Commercial |
$77.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
MNT-RE-ASSESS 15 MIN
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT 97803
|
| Hospital Charge Code |
2050001
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$24.84 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: First Health Workers Compensation |
$35.14
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Worker's Compensation |
$24.84
|
|
|
MOBILIZATION OF COLON
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
CPT 44139
|
| Hospital Charge Code |
6144139
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$105.65 |
| Max. Negotiated Rate |
$367.65 |
| Rate for Payer: Cash Price |
$232.20
|
| Rate for Payer: Cigna Commercial |
$328.95
|
| Rate for Payer: First Health Commercial |
$348.30
|
| Rate for Payer: First Health Workers Compensation |
$149.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$348.30
|
| Rate for Payer: GEHA Commercial |
$270.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$348.30
|
| Rate for Payer: Multiplan All |
$352.17
|
| Rate for Payer: OMNI Networks Commercial |
$270.90
|
| Rate for Payer: One Health Plan PPO/POS |
$348.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$367.65
|
| Rate for Payer: Three Rivers Provider Network All |
$290.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$359.91
|
| Rate for Payer: Zelis Auto |
$154.80
|
| Rate for Payer: Zelis Worker's Compensation |
$105.65
|
|
