|
NO SHOW - PAP SMEAR
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
21500009
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$29.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$19.76
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$45.60
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$38.00
|
| Rate for Payer: Zelis Worker's Compensation |
$20.75
|
|
|
NRPSYC TST EVAL PHYS/QHP 1ST
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
CPT 96132
|
| Hospital Charge Code |
4397913
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$90.91 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$283.05
|
| Rate for Payer: First Health Commercial |
$299.70
|
| Rate for Payer: First Health Workers Compensation |
$128.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$299.70
|
| Rate for Payer: GEHA Commercial |
$233.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$299.70
|
| Rate for Payer: Multiplan All |
$303.03
|
| Rate for Payer: OMNI Networks Commercial |
$233.10
|
| Rate for Payer: One Health Plan PPO/POS |
$299.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$316.35
|
| Rate for Payer: Three Rivers Provider Network All |
$249.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$309.69
|
| Rate for Payer: Zelis Auto |
$133.20
|
| Rate for Payer: Zelis Worker's Compensation |
$90.91
|
|
|
NRPSYC TST EVAL PHYS/QHP 1ST
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
CPT 96132
|
| Hospital Charge Code |
4397913
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$90.91 |
| Max. Negotiated Rate |
$1,007.66 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$199.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$161.55
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$503.83
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$283.05
|
| Rate for Payer: First Health Commercial |
$299.70
|
| Rate for Payer: First Health Workers Compensation |
$128.57
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$299.70
|
| Rate for Payer: GEHA Commercial |
$266.40
|
| Rate for Payer: GEHA Medicare |
$503.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$299.70
|
| Rate for Payer: Humana ChoiceCare |
$554.21
|
| Rate for Payer: Humana Medicare Advantage |
$503.83
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$846.43
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$164.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$503.83
|
| Rate for Payer: Multiplan All |
$303.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$856.51
|
| Rate for Payer: OMNI Networks Commercial |
$233.10
|
| Rate for Payer: One Health Plan PPO/POS |
$299.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$190.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$164.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$503.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$316.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,007.66
|
| Rate for Payer: Three Rivers Provider Network All |
$249.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$493.75
|
| Rate for Payer: United Healthcare Commercial |
$283.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$164.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$503.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$309.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$503.83
|
| Rate for Payer: Zelis Auto |
$133.20
|
| Rate for Payer: Zelis Medicare |
$428.26
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$604.60
|
| Rate for Payer: Zelis Worker's Compensation |
$90.91
|
|
|
NRPSYC TST EVAL PHYS/QHP EA
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
CPT 96133
|
| Hospital Charge Code |
4397914
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$242.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$209.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$209.59
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$166.04
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$216.75
|
| Rate for Payer: First Health Commercial |
$229.50
|
| Rate for Payer: First Health Workers Compensation |
$98.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$229.50
|
| Rate for Payer: GEHA Commercial |
$204.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$229.50
|
| Rate for Payer: Humana ChoiceCare |
$66.30
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$169.42
|
| Rate for Payer: Multiplan All |
$232.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$153.00
|
| Rate for Payer: OMNI Networks Commercial |
$178.50
|
| Rate for Payer: One Health Plan PPO/POS |
$229.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$195.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$169.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$242.25
|
| Rate for Payer: Three Rivers Provider Network All |
$191.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$224.40
|
| Rate for Payer: United Healthcare Commercial |
$216.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$169.42
|
| Rate for Payer: United Payors & United Providers UP&UP |
$237.15
|
| Rate for Payer: Zelis Auto |
$102.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$127.50
|
| Rate for Payer: Zelis Worker's Compensation |
$69.61
|
|
|
NRPSYC TST EVAL PHYS/QHP EA
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
CPT 96133
|
| Hospital Charge Code |
4397914
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$69.61 |
| Max. Negotiated Rate |
$242.25 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$216.75
|
| Rate for Payer: First Health Commercial |
$229.50
|
| Rate for Payer: First Health Workers Compensation |
$98.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$229.50
|
| Rate for Payer: GEHA Commercial |
$178.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$229.50
|
| Rate for Payer: Multiplan All |
$232.05
|
| Rate for Payer: OMNI Networks Commercial |
$178.50
|
| Rate for Payer: One Health Plan PPO/POS |
$229.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$242.25
|
| Rate for Payer: Three Rivers Provider Network All |
$191.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$237.15
|
| Rate for Payer: Zelis Auto |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$69.61
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN+ TOT TIME
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
CPT 99316
|
| Hospital Charge Code |
9400071
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$88.18 |
| Max. Negotiated Rate |
$306.85 |
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: First Health Commercial |
$290.70
|
| Rate for Payer: First Health Workers Compensation |
$124.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$290.70
|
| Rate for Payer: GEHA Commercial |
$226.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$290.70
|
| Rate for Payer: Multiplan All |
$293.93
|
| Rate for Payer: OMNI Networks Commercial |
$226.10
|
| Rate for Payer: One Health Plan PPO/POS |
$290.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$306.85
|
| Rate for Payer: Three Rivers Provider Network All |
$242.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$300.39
|
| Rate for Payer: Zelis Auto |
$129.20
|
| Rate for Payer: Zelis Worker's Compensation |
$88.18
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN+ TOT TIME
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
CPT 99316
|
| Hospital Charge Code |
8599316
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$306.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: First Health Commercial |
$290.70
|
| Rate for Payer: First Health Workers Compensation |
$124.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$290.70
|
| Rate for Payer: GEHA Commercial |
$258.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$290.70
|
| Rate for Payer: Humana ChoiceCare |
$83.98
|
| Rate for Payer: Multiplan All |
$293.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$193.80
|
| Rate for Payer: OMNI Networks Commercial |
$226.10
|
| Rate for Payer: One Health Plan PPO/POS |
$290.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$306.85
|
| Rate for Payer: Three Rivers Provider Network All |
$242.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$284.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$80.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$300.39
|
| Rate for Payer: Zelis Auto |
$129.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$161.50
|
| Rate for Payer: Zelis Worker's Compensation |
$88.18
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN+ TOT TIME
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
CPT 99316
|
| Hospital Charge Code |
8599316
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$88.18 |
| Max. Negotiated Rate |
$306.85 |
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: First Health Commercial |
$290.70
|
| Rate for Payer: First Health Workers Compensation |
$124.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$290.70
|
| Rate for Payer: GEHA Commercial |
$226.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$290.70
|
| Rate for Payer: Multiplan All |
$293.93
|
| Rate for Payer: OMNI Networks Commercial |
$226.10
|
| Rate for Payer: One Health Plan PPO/POS |
$290.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$306.85
|
| Rate for Payer: Three Rivers Provider Network All |
$242.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$300.39
|
| Rate for Payer: Zelis Auto |
$129.20
|
| Rate for Payer: Zelis Worker's Compensation |
$88.18
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN+ TOT TIME
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
CPT 99316
|
| Hospital Charge Code |
9400071
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$306.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$274.55
|
| Rate for Payer: First Health Commercial |
$290.70
|
| Rate for Payer: First Health Workers Compensation |
$124.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$290.70
|
| Rate for Payer: GEHA Commercial |
$258.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$290.70
|
| Rate for Payer: Humana ChoiceCare |
$83.98
|
| Rate for Payer: Multiplan All |
$293.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$193.80
|
| Rate for Payer: OMNI Networks Commercial |
$226.10
|
| Rate for Payer: One Health Plan PPO/POS |
$290.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$306.85
|
| Rate for Payer: Three Rivers Provider Network All |
$242.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$284.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$80.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$300.39
|
| Rate for Payer: Zelis Auto |
$129.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$161.50
|
| Rate for Payer: Zelis Worker's Compensation |
$88.18
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN/<TOT TIME
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 99315
|
| Hospital Charge Code |
8599315
|
|
Hospital Revenue Code
|
524
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$212.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: First Health Commercial |
$201.60
|
| Rate for Payer: First Health Workers Compensation |
$86.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$201.60
|
| Rate for Payer: GEHA Commercial |
$179.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$201.60
|
| Rate for Payer: Humana ChoiceCare |
$58.24
|
| Rate for Payer: Multiplan All |
$203.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$134.40
|
| Rate for Payer: OMNI Networks Commercial |
$156.80
|
| Rate for Payer: One Health Plan PPO/POS |
$201.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$212.80
|
| Rate for Payer: Three Rivers Provider Network All |
$168.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$197.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$56.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$208.32
|
| Rate for Payer: Zelis Auto |
$89.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$112.00
|
| Rate for Payer: Zelis Worker's Compensation |
$61.15
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN/<TOT TIME
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 99315
|
| Hospital Charge Code |
9400070
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$55.75 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cigna Commercial |
$189.55
|
| Rate for Payer: First Health Commercial |
$200.70
|
| Rate for Payer: First Health Workers Compensation |
$86.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$200.70
|
| Rate for Payer: GEHA Commercial |
$178.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$200.70
|
| Rate for Payer: Humana ChoiceCare |
$57.98
|
| Rate for Payer: Multiplan All |
$202.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$133.80
|
| Rate for Payer: OMNI Networks Commercial |
$156.10
|
| Rate for Payer: One Health Plan PPO/POS |
$200.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$211.85
|
| Rate for Payer: Three Rivers Provider Network All |
$167.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$196.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$207.39
|
| Rate for Payer: Zelis Auto |
$89.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$111.50
|
| Rate for Payer: Zelis Worker's Compensation |
$60.88
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN/<TOT TIME
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 99315
|
| Hospital Charge Code |
8599315
|
|
Hospital Revenue Code
|
524
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$212.80 |
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: First Health Commercial |
$201.60
|
| Rate for Payer: First Health Workers Compensation |
$86.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$201.60
|
| Rate for Payer: GEHA Commercial |
$156.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$201.60
|
| Rate for Payer: Multiplan All |
$203.84
|
| Rate for Payer: OMNI Networks Commercial |
$156.80
|
| Rate for Payer: One Health Plan PPO/POS |
$201.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$212.80
|
| Rate for Payer: Three Rivers Provider Network All |
$168.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$208.32
|
| Rate for Payer: Zelis Auto |
$89.60
|
| Rate for Payer: Zelis Worker's Compensation |
$61.15
|
|
|
NRSNG FACILITY D/C MGMT 30 MIN/<TOT TIME
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 99315
|
| Hospital Charge Code |
9400070
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$60.88 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cigna Commercial |
$189.55
|
| Rate for Payer: First Health Commercial |
$200.70
|
| Rate for Payer: First Health Workers Compensation |
$86.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$200.70
|
| Rate for Payer: GEHA Commercial |
$156.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$200.70
|
| Rate for Payer: Multiplan All |
$202.93
|
| Rate for Payer: OMNI Networks Commercial |
$156.10
|
| Rate for Payer: One Health Plan PPO/POS |
$200.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$211.85
|
| Rate for Payer: Three Rivers Provider Network All |
$167.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$207.39
|
| Rate for Payer: Zelis Auto |
$89.20
|
| Rate for Payer: Zelis Worker's Compensation |
$60.88
|
|
|
NRV RPR W/NRV ALGRFT 1ST
|
Facility
|
IP
|
$2,470.00
|
|
|
Service Code
|
CPT 64912
|
| Hospital Charge Code |
6169677
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$674.31 |
| Max. Negotiated Rate |
$2,346.50 |
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$2,099.50
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: First Health Workers Compensation |
$953.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,223.00
|
| Rate for Payer: GEHA Commercial |
$1,729.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,223.00
|
| Rate for Payer: Multiplan All |
$2,247.70
|
| Rate for Payer: OMNI Networks Commercial |
$1,729.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,223.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,346.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,852.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,297.10
|
| Rate for Payer: Zelis Auto |
$988.00
|
| Rate for Payer: Zelis Worker's Compensation |
$674.31
|
|
|
NRV RPR W/NRV ALGRFT 1ST
|
Facility
|
OP
|
$2,470.00
|
|
|
Service Code
|
CPT 64912
|
| Hospital Charge Code |
6169677
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$674.31 |
| Max. Negotiated Rate |
$12,161.84 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$6,940.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,482.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$6,940.90
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$5,498.58
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$6,080.92
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$2,099.50
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: First Health Workers Compensation |
$953.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,223.00
|
| Rate for Payer: GEHA Commercial |
$1,976.00
|
| Rate for Payer: GEHA Medicare |
$6,080.92
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,223.00
|
| Rate for Payer: Humana ChoiceCare |
$6,689.01
|
| Rate for Payer: Humana Medicare Advantage |
$6,080.92
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$10,215.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$5,610.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$6,080.92
|
| Rate for Payer: Multiplan All |
$2,247.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,337.56
|
| Rate for Payer: OMNI Networks Commercial |
$1,729.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,223.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$6,478.18
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$5,610.56
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$6,080.92
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,346.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$12,161.84
|
| Rate for Payer: Three Rivers Provider Network All |
$1,852.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,959.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,610.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,080.92
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,297.10
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$6,080.92
|
| Rate for Payer: Zelis Auto |
$988.00
|
| Rate for Payer: Zelis Medicare |
$5,168.78
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,297.10
|
| Rate for Payer: Zelis Worker's Compensation |
$674.31
|
|
|
NRV RPR W/NRV ALGRFT EA ADDTL
|
Facility
|
OP
|
$2,470.00
|
|
|
Service Code
|
CPT 64913
|
| Hospital Charge Code |
6169678
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$617.50 |
| Max. Negotiated Rate |
$2,346.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,482.00
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$2,099.50
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: First Health Workers Compensation |
$953.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,223.00
|
| Rate for Payer: GEHA Commercial |
$1,976.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,223.00
|
| Rate for Payer: Humana ChoiceCare |
$642.20
|
| Rate for Payer: Multiplan All |
$2,247.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,482.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,729.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,223.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,346.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,852.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,173.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$617.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,297.10
|
| Rate for Payer: Zelis Auto |
$988.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,235.00
|
| Rate for Payer: Zelis Worker's Compensation |
$674.31
|
|
|
NRV RPR W/NRV ALGRFT EA ADDTL
|
Facility
|
IP
|
$2,470.00
|
|
|
Service Code
|
CPT 64913
|
| Hospital Charge Code |
6169678
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$674.31 |
| Max. Negotiated Rate |
$2,346.50 |
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$2,099.50
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: First Health Workers Compensation |
$953.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,223.00
|
| Rate for Payer: GEHA Commercial |
$1,729.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,223.00
|
| Rate for Payer: Multiplan All |
$2,247.70
|
| Rate for Payer: OMNI Networks Commercial |
$1,729.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,223.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,346.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,852.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,297.10
|
| Rate for Payer: Zelis Auto |
$988.00
|
| Rate for Payer: Zelis Worker's Compensation |
$674.31
|
|
|
NS 0.9% 50 ML IVPB
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$12.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Humana ChoiceCare |
$4.16
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9.60
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.00
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
NS 0.9% 50 ML IVPB
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: First Health Commercial |
$14.40
|
| Rate for Payer: First Health Workers Compensation |
$6.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14.40
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14.40
|
| Rate for Payer: Multiplan All |
$14.56
|
| Rate for Payer: OMNI Networks Commercial |
$11.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15.20
|
| Rate for Payer: Three Rivers Provider Network All |
$12.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14.88
|
| Rate for Payer: Zelis Auto |
$6.40
|
| Rate for Payer: Zelis Worker's Compensation |
$4.37
|
|
|
NS (0.9% NACL) 1000 ML BOLUS
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3303233
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$11.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
NS (0.9% NACL) 1000 ML BOLUS
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
3303233
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$14.45
|
| Rate for Payer: First Health Commercial |
$15.30
|
| Rate for Payer: First Health Workers Compensation |
$6.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15.30
|
| Rate for Payer: GEHA Commercial |
$2.15
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15.30
|
| Rate for Payer: Humana ChoiceCare |
$4.42
|
| Rate for Payer: Multiplan All |
$15.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10.20
|
| Rate for Payer: OMNI Networks Commercial |
$11.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16.15
|
| Rate for Payer: Three Rivers Provider Network All |
$12.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15.81
|
| Rate for Payer: Zelis Auto |
$6.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8.50
|
| Rate for Payer: Zelis Worker's Compensation |
$4.64
|
|
|
NS (0.9% NACL)100 ML IVPB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301132
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
NS (0.9% NACL)100 ML IVPB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
3301132
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
NS 100ML BAG
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00338004948
|
| Hospital Charge Code |
3301136
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$7.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
|
NS 100ML BAG
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00338004948
|
| Hospital Charge Code |
3301136
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$9.35
|
| Rate for Payer: First Health Commercial |
$9.90
|
| Rate for Payer: First Health Workers Compensation |
$4.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.90
|
| Rate for Payer: GEHA Commercial |
$8.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.90
|
| Rate for Payer: Humana ChoiceCare |
$2.86
|
| Rate for Payer: Multiplan All |
$10.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.60
|
| Rate for Payer: OMNI Networks Commercial |
$7.70
|
| Rate for Payer: One Health Plan PPO/POS |
$9.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10.45
|
| Rate for Payer: Three Rivers Provider Network All |
$8.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10.23
|
| Rate for Payer: Zelis Auto |
$4.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.50
|
| Rate for Payer: Zelis Worker's Compensation |
$3.00
|
|
