|
NJX DX/THER AGT PVRT FACET JT L/S 1 LVL
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
6164493
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$75.89 |
| Max. Negotiated Rate |
$1,690.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$166.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$576.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$845.37
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$236.30
|
| Rate for Payer: First Health Commercial |
$250.20
|
| Rate for Payer: First Health Workers Compensation |
$107.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$250.20
|
| Rate for Payer: GEHA Commercial |
$222.40
|
| Rate for Payer: GEHA Medicare |
$845.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$250.20
|
| Rate for Payer: Humana ChoiceCare |
$929.91
|
| Rate for Payer: Humana Medicare Advantage |
$845.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,420.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$588.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$845.37
|
| Rate for Payer: Multiplan All |
$252.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,437.13
|
| Rate for Payer: OMNI Networks Commercial |
$194.60
|
| Rate for Payer: One Health Plan PPO/POS |
$250.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$679.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$588.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$845.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$264.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,690.74
|
| Rate for Payer: Three Rivers Provider Network All |
$208.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$828.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$588.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$845.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$258.54
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$845.37
|
| Rate for Payer: Zelis Auto |
$111.20
|
| Rate for Payer: Zelis Medicare |
$718.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,014.44
|
| Rate for Payer: Zelis Worker's Compensation |
$75.89
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
21900156
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
21900156
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$67.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.40
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
6164494
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$70.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
6164494
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$67.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.40
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
21764494
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$67.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.40
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
7664494
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$155.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$207.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Humana ChoiceCare |
$67.34
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$155.40
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$227.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$129.50
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
21764494
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 2 LVL
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
7664494
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$70.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$220.15
|
| Rate for Payer: First Health Commercial |
$233.10
|
| Rate for Payer: First Health Workers Compensation |
$100.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$233.10
|
| Rate for Payer: GEHA Commercial |
$181.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$233.10
|
| Rate for Payer: Multiplan All |
$235.69
|
| Rate for Payer: OMNI Networks Commercial |
$181.30
|
| Rate for Payer: One Health Plan PPO/POS |
$233.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$246.05
|
| Rate for Payer: Three Rivers Provider Network All |
$194.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$240.87
|
| Rate for Payer: Zelis Auto |
$103.60
|
| Rate for Payer: Zelis Worker's Compensation |
$70.71
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
21900157
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
21764495
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$208.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
21764495
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
7664495
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$208.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
6164495
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$208.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
6164495
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
21900157
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$258.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$156.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.72
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$208.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Humana ChoiceCare |
$67.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$208.89
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$156.00
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$208.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$228.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$130.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FACET JT L/S 3+ LVL
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
7664495
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
NJX DX/THER AGT PVRT FAC JT C/T 1 LVL BI
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
21900152
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$309.31 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cigna Commercial |
$963.05
|
| Rate for Payer: First Health Commercial |
$1,019.70
|
| Rate for Payer: First Health Workers Compensation |
$437.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,019.70
|
| Rate for Payer: GEHA Commercial |
$793.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,019.70
|
| Rate for Payer: Multiplan All |
$1,031.03
|
| Rate for Payer: OMNI Networks Commercial |
$793.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,019.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,076.35
|
| Rate for Payer: Three Rivers Provider Network All |
$849.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,053.69
|
| Rate for Payer: Zelis Auto |
$453.20
|
| Rate for Payer: Zelis Worker's Compensation |
$309.31
|
|
|
NJX DX/THER AGT PVRT FAC JT C/T 1 LVL BI
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
21764490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$309.31 |
| Max. Negotiated Rate |
$1,690.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$679.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$576.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$845.37
|
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cigna Commercial |
$963.05
|
| Rate for Payer: First Health Commercial |
$1,019.70
|
| Rate for Payer: First Health Workers Compensation |
$437.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,019.70
|
| Rate for Payer: GEHA Commercial |
$906.40
|
| Rate for Payer: GEHA Medicare |
$845.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,019.70
|
| Rate for Payer: Humana ChoiceCare |
$929.91
|
| Rate for Payer: Humana Medicare Advantage |
$845.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,420.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$588.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$845.37
|
| Rate for Payer: Multiplan All |
$1,031.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,437.13
|
| Rate for Payer: OMNI Networks Commercial |
$793.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,019.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$679.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$588.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$845.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,076.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,690.74
|
| Rate for Payer: Three Rivers Provider Network All |
$849.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$828.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$588.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$845.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,053.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$845.37
|
| Rate for Payer: Zelis Auto |
$453.20
|
| Rate for Payer: Zelis Medicare |
$718.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,014.44
|
| Rate for Payer: Zelis Worker's Compensation |
$309.31
|
|
|
NJX DX/THER AGT PVRT FAC JT C/T 1 LVL BI
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
21900152
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$309.31 |
| Max. Negotiated Rate |
$1,690.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$679.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$576.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$845.37
|
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cigna Commercial |
$963.05
|
| Rate for Payer: First Health Commercial |
$1,019.70
|
| Rate for Payer: First Health Workers Compensation |
$437.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,019.70
|
| Rate for Payer: GEHA Commercial |
$906.40
|
| Rate for Payer: GEHA Medicare |
$845.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,019.70
|
| Rate for Payer: Humana ChoiceCare |
$929.91
|
| Rate for Payer: Humana Medicare Advantage |
$845.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,420.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$588.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$845.37
|
| Rate for Payer: Multiplan All |
$1,031.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,437.13
|
| Rate for Payer: OMNI Networks Commercial |
$793.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,019.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$679.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$588.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$845.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,076.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,690.74
|
| Rate for Payer: Three Rivers Provider Network All |
$849.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$828.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$588.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$845.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,053.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$845.37
|
| Rate for Payer: Zelis Auto |
$453.20
|
| Rate for Payer: Zelis Medicare |
$718.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,014.44
|
| Rate for Payer: Zelis Worker's Compensation |
$309.31
|
|
|
NJX DX/THER AGT PVRT FAC JT C/T 1 LVL BI
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
21764490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$309.31 |
| Max. Negotiated Rate |
$1,076.35 |
| Rate for Payer: Cash Price |
$679.80
|
| Rate for Payer: Cigna Commercial |
$963.05
|
| Rate for Payer: First Health Commercial |
$1,019.70
|
| Rate for Payer: First Health Workers Compensation |
$437.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,019.70
|
| Rate for Payer: GEHA Commercial |
$793.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,019.70
|
| Rate for Payer: Multiplan All |
$1,031.03
|
| Rate for Payer: OMNI Networks Commercial |
$793.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,019.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,076.35
|
| Rate for Payer: Three Rivers Provider Network All |
$849.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,053.69
|
| Rate for Payer: Zelis Auto |
$453.20
|
| Rate for Payer: Zelis Worker's Compensation |
$309.31
|
|
|
NJX DX/THER AGT PVRT FAC JT L/S 1 LVL BI
|
Facility
|
OP
|
$1,027.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
21764493
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$280.37 |
| Max. Negotiated Rate |
$1,690.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$616.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$576.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$845.37
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cigna Commercial |
$872.95
|
| Rate for Payer: First Health Commercial |
$924.30
|
| Rate for Payer: First Health Workers Compensation |
$396.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$924.30
|
| Rate for Payer: GEHA Commercial |
$821.60
|
| Rate for Payer: GEHA Medicare |
$845.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$924.30
|
| Rate for Payer: Humana ChoiceCare |
$929.91
|
| Rate for Payer: Humana Medicare Advantage |
$845.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,420.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$588.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$845.37
|
| Rate for Payer: Multiplan All |
$934.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,437.13
|
| Rate for Payer: OMNI Networks Commercial |
$718.90
|
| Rate for Payer: One Health Plan PPO/POS |
$924.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$679.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$588.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$845.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$975.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,690.74
|
| Rate for Payer: Three Rivers Provider Network All |
$770.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$828.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$588.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$845.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$955.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$845.37
|
| Rate for Payer: Zelis Auto |
$410.80
|
| Rate for Payer: Zelis Medicare |
$718.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,014.44
|
| Rate for Payer: Zelis Worker's Compensation |
$280.37
|
|
|
NJX DX/THER AGT PVRT FAC JT L/S 1 LVL BI
|
Facility
|
OP
|
$1,027.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
21900155
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$280.37 |
| Max. Negotiated Rate |
$1,690.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$616.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$728.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$576.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$845.37
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cigna Commercial |
$872.95
|
| Rate for Payer: First Health Commercial |
$924.30
|
| Rate for Payer: First Health Workers Compensation |
$396.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$924.30
|
| Rate for Payer: GEHA Commercial |
$821.60
|
| Rate for Payer: GEHA Medicare |
$845.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$924.30
|
| Rate for Payer: Humana ChoiceCare |
$929.91
|
| Rate for Payer: Humana Medicare Advantage |
$845.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,420.22
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$588.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$845.37
|
| Rate for Payer: Multiplan All |
$934.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,437.13
|
| Rate for Payer: OMNI Networks Commercial |
$718.90
|
| Rate for Payer: One Health Plan PPO/POS |
$924.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$679.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$588.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$845.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$975.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,690.74
|
| Rate for Payer: Three Rivers Provider Network All |
$770.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$828.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$588.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$845.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$955.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$845.37
|
| Rate for Payer: Zelis Auto |
$410.80
|
| Rate for Payer: Zelis Medicare |
$718.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,014.44
|
| Rate for Payer: Zelis Worker's Compensation |
$280.37
|
|
|
NJX DX/THER AGT PVRT FAC JT L/S 1 LVL BI
|
Facility
|
IP
|
$1,027.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
21900155
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$280.37 |
| Max. Negotiated Rate |
$975.65 |
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cigna Commercial |
$872.95
|
| Rate for Payer: First Health Commercial |
$924.30
|
| Rate for Payer: First Health Workers Compensation |
$396.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$924.30
|
| Rate for Payer: GEHA Commercial |
$718.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$924.30
|
| Rate for Payer: Multiplan All |
$934.57
|
| Rate for Payer: OMNI Networks Commercial |
$718.90
|
| Rate for Payer: One Health Plan PPO/POS |
$924.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$975.65
|
| Rate for Payer: Three Rivers Provider Network All |
$770.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$955.11
|
| Rate for Payer: Zelis Auto |
$410.80
|
| Rate for Payer: Zelis Worker's Compensation |
$280.37
|
|
|
NJX DX/THER AGT PVRT FAC JT L/S 1 LVL BI
|
Facility
|
IP
|
$1,027.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
21764493
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$280.37 |
| Max. Negotiated Rate |
$975.65 |
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cigna Commercial |
$872.95
|
| Rate for Payer: First Health Commercial |
$924.30
|
| Rate for Payer: First Health Workers Compensation |
$396.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$924.30
|
| Rate for Payer: GEHA Commercial |
$718.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$924.30
|
| Rate for Payer: Multiplan All |
$934.57
|
| Rate for Payer: OMNI Networks Commercial |
$718.90
|
| Rate for Payer: One Health Plan PPO/POS |
$924.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$975.65
|
| Rate for Payer: Three Rivers Provider Network All |
$770.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$955.11
|
| Rate for Payer: Zelis Auto |
$410.80
|
| Rate for Payer: Zelis Worker's Compensation |
$280.37
|
|
