|
MRI LE NON-JNT W/O RT
|
Facility
|
OP
|
$3,946.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
2002027
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$3,748.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,367.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$2,367.60
|
| Rate for Payer: Cash Price |
$2,367.60
|
| Rate for Payer: Cigna Commercial |
$3,354.10
|
| Rate for Payer: First Health Commercial |
$3,551.40
|
| Rate for Payer: First Health Workers Compensation |
$569.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,551.40
|
| Rate for Payer: GEHA Commercial |
$3,156.80
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,551.40
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$3,590.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$2,762.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,551.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,748.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$2,959.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$3,354.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,669.78
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$1,578.40
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$402.61
|
|
|
MRI LE NON-JNT W/WO
|
Facility
|
OP
|
$5,201.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
2410107
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$4,940.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,120.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$636.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cigna Commercial |
$4,420.85
|
| Rate for Payer: First Health Commercial |
$4,680.90
|
| Rate for Payer: First Health Workers Compensation |
$792.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,680.90
|
| Rate for Payer: GEHA Commercial |
$4,160.80
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,680.90
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$649.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$4,732.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,640.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,680.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$749.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$649.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,940.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,900.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$4,420.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$649.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,836.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$2,080.40
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$560.65
|
|
|
MRI LE NON-JNT W/WO
|
Facility
|
IP
|
$5,201.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
2410107
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$560.65 |
| Max. Negotiated Rate |
$4,940.95 |
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cigna Commercial |
$4,420.85
|
| Rate for Payer: First Health Commercial |
$4,680.90
|
| Rate for Payer: First Health Workers Compensation |
$792.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,680.90
|
| Rate for Payer: GEHA Commercial |
$3,640.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,680.90
|
| Rate for Payer: Multiplan All |
$4,732.91
|
| Rate for Payer: OMNI Networks Commercial |
$3,640.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,680.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,940.95
|
| Rate for Payer: Three Rivers Provider Network All |
$3,900.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,836.93
|
| Rate for Payer: Zelis Auto |
$2,080.40
|
| Rate for Payer: Zelis Worker's Compensation |
$560.65
|
|
|
MRI LE NON-JNT W/WO RT
|
Facility
|
OP
|
$5,201.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
2000173
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$4,940.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,120.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$636.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cigna Commercial |
$4,420.85
|
| Rate for Payer: First Health Commercial |
$4,680.90
|
| Rate for Payer: First Health Workers Compensation |
$792.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,680.90
|
| Rate for Payer: GEHA Commercial |
$4,160.80
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,680.90
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$649.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$4,732.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,640.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,680.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$749.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$649.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,940.95
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,900.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$4,420.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$649.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,836.93
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$2,080.40
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$560.65
|
|
|
MRI LE NON-JNT W/WO RT
|
Facility
|
IP
|
$5,201.00
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
2000173
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$560.65 |
| Max. Negotiated Rate |
$4,940.95 |
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cash Price |
$3,120.60
|
| Rate for Payer: Cigna Commercial |
$4,420.85
|
| Rate for Payer: First Health Commercial |
$4,680.90
|
| Rate for Payer: First Health Workers Compensation |
$792.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,680.90
|
| Rate for Payer: GEHA Commercial |
$3,640.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,680.90
|
| Rate for Payer: Multiplan All |
$4,732.91
|
| Rate for Payer: OMNI Networks Commercial |
$3,640.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,680.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,940.95
|
| Rate for Payer: Three Rivers Provider Network All |
$3,900.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,836.93
|
| Rate for Payer: Zelis Auto |
$2,080.40
|
| Rate for Payer: Zelis Worker's Compensation |
$560.65
|
|
|
MRI LOW EXT NO JOINT WC RIGHT
|
Facility
|
OP
|
$4,060.00
|
|
|
Service Code
|
CPT 73719
|
| Hospital Charge Code |
2001115
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$3,857.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,436.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$503.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cigna Commercial |
$3,451.00
|
| Rate for Payer: First Health Commercial |
$3,654.00
|
| Rate for Payer: First Health Workers Compensation |
$649.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,654.00
|
| Rate for Payer: GEHA Commercial |
$3,248.00
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,654.00
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$514.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$3,694.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$2,842.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,654.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$593.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$514.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,857.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,045.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$3,451.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$514.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,775.80
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$1,624.00
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$459.31
|
|
|
MRI LOW EXT NO JOINT WC RIGHT
|
Facility
|
IP
|
$4,060.00
|
|
|
Service Code
|
CPT 73719
|
| Hospital Charge Code |
2001115
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$459.31 |
| Max. Negotiated Rate |
$3,857.00 |
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cash Price |
$2,436.00
|
| Rate for Payer: Cigna Commercial |
$3,451.00
|
| Rate for Payer: First Health Commercial |
$3,654.00
|
| Rate for Payer: First Health Workers Compensation |
$649.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,654.00
|
| Rate for Payer: GEHA Commercial |
$2,842.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,654.00
|
| Rate for Payer: Multiplan All |
$3,694.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,842.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,654.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,857.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,045.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,775.80
|
| Rate for Payer: Zelis Auto |
$1,624.00
|
| Rate for Payer: Zelis Worker's Compensation |
$459.31
|
|
|
MRI L-SPINE W/CON
|
Facility
|
OP
|
$4,844.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
2000174
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$4,601.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,906.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$503.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$2,906.40
|
| Rate for Payer: Cash Price |
$2,906.40
|
| Rate for Payer: Cigna Commercial |
$4,117.40
|
| Rate for Payer: First Health Commercial |
$4,359.60
|
| Rate for Payer: First Health Workers Compensation |
$661.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,359.60
|
| Rate for Payer: GEHA Commercial |
$3,875.20
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,359.60
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$514.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$4,408.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,390.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,359.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$593.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$514.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,601.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,633.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$4,117.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$514.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,504.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$1,937.60
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$467.80
|
|
|
MRI L-SPINE W/CON
|
Facility
|
IP
|
$4,844.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
2000174
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$467.80 |
| Max. Negotiated Rate |
$4,601.80 |
| Rate for Payer: Cash Price |
$2,906.40
|
| Rate for Payer: Cash Price |
$2,906.40
|
| Rate for Payer: Cigna Commercial |
$4,117.40
|
| Rate for Payer: First Health Commercial |
$4,359.60
|
| Rate for Payer: First Health Workers Compensation |
$661.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,359.60
|
| Rate for Payer: GEHA Commercial |
$3,390.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,359.60
|
| Rate for Payer: Multiplan All |
$4,408.04
|
| Rate for Payer: OMNI Networks Commercial |
$3,390.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,359.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,601.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,633.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,504.92
|
| Rate for Payer: Zelis Auto |
$1,937.60
|
| Rate for Payer: Zelis Worker's Compensation |
$467.80
|
|
|
MRI L-SPINE W/O
|
Facility
|
IP
|
$4,372.30
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
2000184
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$405.74 |
| Max. Negotiated Rate |
$4,153.69 |
| Rate for Payer: Cash Price |
$2,623.38
|
| Rate for Payer: Cash Price |
$2,623.38
|
| Rate for Payer: Cigna Commercial |
$3,716.45
|
| Rate for Payer: First Health Commercial |
$3,935.07
|
| Rate for Payer: First Health Workers Compensation |
$573.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,935.07
|
| Rate for Payer: GEHA Commercial |
$3,060.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,935.07
|
| Rate for Payer: Multiplan All |
$3,978.79
|
| Rate for Payer: OMNI Networks Commercial |
$3,060.61
|
| Rate for Payer: One Health Plan PPO/POS |
$3,935.07
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,153.69
|
| Rate for Payer: Three Rivers Provider Network All |
$3,279.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,066.24
|
| Rate for Payer: Zelis Auto |
$1,748.92
|
| Rate for Payer: Zelis Worker's Compensation |
$405.74
|
|
|
MRI L-SPINE W/O
|
Facility
|
OP
|
$4,372.30
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
2000184
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$4,153.69 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,623.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$2,623.38
|
| Rate for Payer: Cash Price |
$2,623.38
|
| Rate for Payer: Cigna Commercial |
$3,716.45
|
| Rate for Payer: First Health Commercial |
$3,935.07
|
| Rate for Payer: First Health Workers Compensation |
$573.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,935.07
|
| Rate for Payer: GEHA Commercial |
$3,497.84
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,935.07
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$3,978.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$3,060.61
|
| Rate for Payer: One Health Plan PPO/POS |
$3,935.07
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,153.69
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$3,279.22
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$3,716.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,066.24
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$1,748.92
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$405.74
|
|
|
MRI L-SPINE W/WO
|
Facility
|
OP
|
$5,907.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
2000175
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$5,611.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,544.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$636.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$3,544.20
|
| Rate for Payer: Cash Price |
$3,544.20
|
| Rate for Payer: Cigna Commercial |
$5,020.95
|
| Rate for Payer: First Health Commercial |
$5,316.30
|
| Rate for Payer: First Health Workers Compensation |
$818.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,316.30
|
| Rate for Payer: GEHA Commercial |
$4,725.60
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,316.30
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$649.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$5,375.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$4,134.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,316.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$749.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$649.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,611.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$4,430.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$5,020.95
|
| Rate for Payer: United Healthcare Managed Medicaid |
$649.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,493.51
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$2,362.80
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$578.83
|
|
|
MRI L-SPINE W/WO
|
Facility
|
IP
|
$5,907.00
|
|
|
Service Code
|
CPT 72158
|
| Hospital Charge Code |
2000175
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$578.83 |
| Max. Negotiated Rate |
$5,611.65 |
| Rate for Payer: Cash Price |
$3,544.20
|
| Rate for Payer: Cash Price |
$3,544.20
|
| Rate for Payer: Cigna Commercial |
$5,020.95
|
| Rate for Payer: First Health Commercial |
$5,316.30
|
| Rate for Payer: First Health Workers Compensation |
$818.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,316.30
|
| Rate for Payer: GEHA Commercial |
$4,134.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,316.30
|
| Rate for Payer: Multiplan All |
$5,375.37
|
| Rate for Payer: OMNI Networks Commercial |
$4,134.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,316.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,611.65
|
| Rate for Payer: Three Rivers Provider Network All |
$4,430.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,493.51
|
| Rate for Payer: Zelis Auto |
$2,362.80
|
| Rate for Payer: Zelis Worker's Compensation |
$578.83
|
|
|
MRI MRCP (MRI ABD W/O)
|
Facility
|
IP
|
$4,100.00
|
|
|
Service Code
|
CPT 74181
|
| Hospital Charge Code |
2074181
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$393.06 |
| Max. Negotiated Rate |
$3,895.00 |
| Rate for Payer: Cash Price |
$2,460.00
|
| Rate for Payer: Cash Price |
$2,460.00
|
| Rate for Payer: Cigna Commercial |
$3,485.00
|
| Rate for Payer: First Health Commercial |
$3,690.00
|
| Rate for Payer: First Health Workers Compensation |
$555.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,690.00
|
| Rate for Payer: GEHA Commercial |
$2,870.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,690.00
|
| Rate for Payer: Multiplan All |
$3,731.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,870.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,690.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,895.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,075.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,813.00
|
| Rate for Payer: Zelis Auto |
$1,640.00
|
| Rate for Payer: Zelis Worker's Compensation |
$393.06
|
|
|
MRI MRCP (MRI ABD W/O)
|
Facility
|
OP
|
$4,100.00
|
|
|
Service Code
|
CPT 74181
|
| Hospital Charge Code |
2074181
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$3,895.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,460.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$2,460.00
|
| Rate for Payer: Cash Price |
$2,460.00
|
| Rate for Payer: Cigna Commercial |
$3,485.00
|
| Rate for Payer: First Health Commercial |
$3,690.00
|
| Rate for Payer: First Health Workers Compensation |
$555.89
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,690.00
|
| Rate for Payer: GEHA Commercial |
$3,280.00
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,690.00
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$3,731.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$2,870.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,690.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,895.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$3,075.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$3,485.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,813.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$1,640.00
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$393.06
|
|
|
MRI ORB/FAC/NEC W/CON
|
Facility
|
OP
|
$4,630.00
|
|
|
Service Code
|
CPT 70542
|
| Hospital Charge Code |
2001112
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$4,398.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,778.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$503.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$2,778.00
|
| Rate for Payer: Cash Price |
$2,778.00
|
| Rate for Payer: Cigna Commercial |
$3,935.50
|
| Rate for Payer: First Health Commercial |
$4,167.00
|
| Rate for Payer: First Health Workers Compensation |
$649.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,167.00
|
| Rate for Payer: GEHA Commercial |
$3,704.00
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,167.00
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$514.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$4,213.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,241.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,167.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$593.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$514.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,398.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,472.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$3,935.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$514.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,305.90
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$1,852.00
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$458.97
|
|
|
MRI ORB/FAC/NEC W/CON
|
Facility
|
IP
|
$4,630.00
|
|
|
Service Code
|
CPT 70542
|
| Hospital Charge Code |
2001112
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$458.97 |
| Max. Negotiated Rate |
$4,398.50 |
| Rate for Payer: Cash Price |
$2,778.00
|
| Rate for Payer: Cash Price |
$2,778.00
|
| Rate for Payer: Cigna Commercial |
$3,935.50
|
| Rate for Payer: First Health Commercial |
$4,167.00
|
| Rate for Payer: First Health Workers Compensation |
$649.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,167.00
|
| Rate for Payer: GEHA Commercial |
$3,241.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,167.00
|
| Rate for Payer: Multiplan All |
$4,213.30
|
| Rate for Payer: OMNI Networks Commercial |
$3,241.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,167.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,398.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,472.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,305.90
|
| Rate for Payer: Zelis Auto |
$1,852.00
|
| Rate for Payer: Zelis Worker's Compensation |
$458.97
|
|
|
MRI ORB/FAC/NEC W/O
|
Facility
|
IP
|
$4,022.00
|
|
|
Service Code
|
CPT 70540
|
| Hospital Charge Code |
2000177
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$406.82 |
| Max. Negotiated Rate |
$3,820.90 |
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cigna Commercial |
$3,418.70
|
| Rate for Payer: First Health Commercial |
$3,619.80
|
| Rate for Payer: First Health Workers Compensation |
$575.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,619.80
|
| Rate for Payer: GEHA Commercial |
$2,815.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,619.80
|
| Rate for Payer: Multiplan All |
$3,660.02
|
| Rate for Payer: OMNI Networks Commercial |
$2,815.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,619.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,820.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,016.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,740.46
|
| Rate for Payer: Zelis Auto |
$1,608.80
|
| Rate for Payer: Zelis Worker's Compensation |
$406.82
|
|
|
MRI ORB/FAC/NEC W/O
|
Facility
|
OP
|
$4,022.00
|
|
|
Service Code
|
CPT 70540
|
| Hospital Charge Code |
2000177
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$3,820.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,413.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cigna Commercial |
$3,418.70
|
| Rate for Payer: First Health Commercial |
$3,619.80
|
| Rate for Payer: First Health Workers Compensation |
$575.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,619.80
|
| Rate for Payer: GEHA Commercial |
$3,217.60
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,619.80
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$3,660.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$2,815.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,619.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,820.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$3,016.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$3,418.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,740.46
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$1,608.80
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$406.82
|
|
|
MRI ORB/FAC/NEC W/WO
|
Facility
|
OP
|
$5,508.00
|
|
|
Service Code
|
CPT 70543
|
| Hospital Charge Code |
2001113
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$5,232.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,304.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$803.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$636.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$3,304.80
|
| Rate for Payer: Cash Price |
$3,304.80
|
| Rate for Payer: Cigna Commercial |
$4,681.80
|
| Rate for Payer: First Health Commercial |
$4,957.20
|
| Rate for Payer: First Health Workers Compensation |
$877.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,957.20
|
| Rate for Payer: GEHA Commercial |
$4,406.40
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,957.20
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$649.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$5,012.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,855.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,957.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$749.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$649.20
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,232.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$4,131.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$4,681.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$649.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,122.44
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$2,203.20
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$620.63
|
|
|
MRI ORB/FAC/NEC W/WO
|
Facility
|
IP
|
$5,508.00
|
|
|
Service Code
|
CPT 70543
|
| Hospital Charge Code |
2001113
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$620.63 |
| Max. Negotiated Rate |
$5,232.60 |
| Rate for Payer: Cash Price |
$3,304.80
|
| Rate for Payer: Cash Price |
$3,304.80
|
| Rate for Payer: Cigna Commercial |
$4,681.80
|
| Rate for Payer: First Health Commercial |
$4,957.20
|
| Rate for Payer: First Health Workers Compensation |
$877.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,957.20
|
| Rate for Payer: GEHA Commercial |
$3,855.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,957.20
|
| Rate for Payer: Multiplan All |
$5,012.28
|
| Rate for Payer: OMNI Networks Commercial |
$3,855.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,957.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,232.60
|
| Rate for Payer: Three Rivers Provider Network All |
$4,131.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,122.44
|
| Rate for Payer: Zelis Auto |
$2,203.20
|
| Rate for Payer: Zelis Worker's Compensation |
$620.63
|
|
|
MRI PELVIS W/CON
|
Facility
|
IP
|
$4,533.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
2000178
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$467.43 |
| Max. Negotiated Rate |
$4,306.35 |
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cigna Commercial |
$3,853.05
|
| Rate for Payer: First Health Commercial |
$4,079.70
|
| Rate for Payer: First Health Workers Compensation |
$661.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,079.70
|
| Rate for Payer: GEHA Commercial |
$3,173.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,079.70
|
| Rate for Payer: Multiplan All |
$4,125.03
|
| Rate for Payer: OMNI Networks Commercial |
$3,173.10
|
| Rate for Payer: One Health Plan PPO/POS |
$4,079.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,306.35
|
| Rate for Payer: Three Rivers Provider Network All |
$3,399.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,215.69
|
| Rate for Payer: Zelis Auto |
$1,813.20
|
| Rate for Payer: Zelis Worker's Compensation |
$467.43
|
|
|
MRI PELVIS W/CON
|
Facility
|
OP
|
$4,533.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
2000178
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$288.24 |
| Max. Negotiated Rate |
$4,306.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,719.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$635.99
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$503.83
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$339.11
|
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cash Price |
$2,719.80
|
| Rate for Payer: Cigna Commercial |
$3,853.05
|
| Rate for Payer: First Health Commercial |
$4,079.70
|
| Rate for Payer: First Health Workers Compensation |
$661.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,079.70
|
| Rate for Payer: GEHA Commercial |
$3,626.40
|
| Rate for Payer: GEHA Medicare |
$339.11
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,079.70
|
| Rate for Payer: Humana ChoiceCare |
$373.02
|
| Rate for Payer: Humana Medicare Advantage |
$339.11
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$569.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$514.09
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$339.11
|
| Rate for Payer: Multiplan All |
$4,125.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.49
|
| Rate for Payer: OMNI Networks Commercial |
$3,173.10
|
| Rate for Payer: One Health Plan PPO/POS |
$4,079.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$593.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$514.09
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$339.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,306.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$678.22
|
| Rate for Payer: Three Rivers Provider Network All |
$3,399.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$332.33
|
| Rate for Payer: United Healthcare Commercial |
$3,853.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$514.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$339.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,215.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$339.11
|
| Rate for Payer: Zelis Auto |
$1,813.20
|
| Rate for Payer: Zelis Medicare |
$288.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$406.93
|
| Rate for Payer: Zelis Worker's Compensation |
$467.43
|
|
|
MRI PELVIS W/O
|
Facility
|
OP
|
$3,910.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
2002013
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$195.09 |
| Max. Negotiated Rate |
$3,714.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,346.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$524.29
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$415.35
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$229.52
|
| Rate for Payer: Cash Price |
$2,346.00
|
| Rate for Payer: Cash Price |
$2,346.00
|
| Rate for Payer: Cigna Commercial |
$3,323.50
|
| Rate for Payer: First Health Commercial |
$3,519.00
|
| Rate for Payer: First Health Workers Compensation |
$575.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,519.00
|
| Rate for Payer: GEHA Commercial |
$3,128.00
|
| Rate for Payer: GEHA Medicare |
$229.52
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,519.00
|
| Rate for Payer: Humana ChoiceCare |
$252.47
|
| Rate for Payer: Humana Medicare Advantage |
$229.52
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$385.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$423.81
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$229.52
|
| Rate for Payer: Multiplan All |
$3,558.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$390.18
|
| Rate for Payer: OMNI Networks Commercial |
$2,737.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,519.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$489.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$423.81
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$229.52
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,714.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$459.04
|
| Rate for Payer: Three Rivers Provider Network All |
$2,932.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.93
|
| Rate for Payer: United Healthcare Commercial |
$3,323.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$423.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.52
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,636.30
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$229.52
|
| Rate for Payer: Zelis Auto |
$1,564.00
|
| Rate for Payer: Zelis Medicare |
$195.09
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.42
|
| Rate for Payer: Zelis Worker's Compensation |
$406.97
|
|
|
MRI PELVIS W/O
|
Facility
|
IP
|
$3,910.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
2002013
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$406.97 |
| Max. Negotiated Rate |
$3,714.50 |
| Rate for Payer: Cash Price |
$2,346.00
|
| Rate for Payer: Cash Price |
$2,346.00
|
| Rate for Payer: Cigna Commercial |
$3,323.50
|
| Rate for Payer: First Health Commercial |
$3,519.00
|
| Rate for Payer: First Health Workers Compensation |
$575.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,519.00
|
| Rate for Payer: GEHA Commercial |
$2,737.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,519.00
|
| Rate for Payer: Multiplan All |
$3,558.10
|
| Rate for Payer: OMNI Networks Commercial |
$2,737.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,519.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,714.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,636.30
|
| Rate for Payer: Zelis Auto |
$1,564.00
|
| Rate for Payer: Zelis Worker's Compensation |
$406.97
|
|
