Statistical Outliers

Single-test outliers in New Mexico Medicaid data. These are individual statistical flags — most are informational.

Important context: These findings identify statistically unusual billing patterns, not determinations of wrongdoing. Cost-per-claim comparisons may flag hospital outpatient departments whose reimbursements include facility fees, bundled services, or all-inclusive rates. High claims-per-beneficiary ratios may reflect legitimate care patterns at behavioral health facilities, pediatric specialty centers, or residential care programs. Additional investigation and clinical context are required before drawing any conclusions.

For provider level analytics using multiple independent tests, see the Watchlist — which flags providers only when 2+ different detection methods agree. These single-test outliers below are primarily informational; only Cost Outliers and Overutilization are flagged as critical/warning.

critical

207

warning

213

info

2,971

Total

3,391

Outliers by Type

Severity Distribution

critical

207 (6.1%)

warning

213 (6.3%)

info

2,971 (87.6%)

2,391 results

criticalCost OutlierScore: 17.5

Cost-per-claim above average for D1208

RAMAH NAVAJO SCHOOL BOARD, INC (1619001849) bills $719.00/claim for D1208 (Topical fluoride excluding varnish) vs avg $20.22 (+17.5σ). $10,785 across 15 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

RAMAH NAVAJO SCHOOL BOARD, INCPINE HILLProvider total: $397.3K

criticalCost OutlierScore: 17.5

Cost-per-claim above average for D0150 (Comprehensive Oral Evaluation (New or Established Patient))

ALAMO NAVAJO SCHOOL BOARD, INC. (1861412777) bills $431.49/claim for D0150 (Comprehensive oral evaluation) vs avg $32.74 (+17.5σ). $131,605 across 305 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALAMO NAVAJO SCHOOL BOARD, INC.ALAMOProvider total: $10.9M

criticalCost OutlierScore: 16.5

Cost-per-claim above average for D0120 (Periodic Oral Evaluation (Established Patient))

ALAMO NAVAJO SCHOOL BOARD, INC. (1861412777) bills $452.44/claim for D0120 (Periodic oral evaluation) vs avg $22.55 (+16.5σ). $91,393 across 202 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALAMO NAVAJO SCHOOL BOARD, INC.ALAMOProvider total: $10.9M

criticalCost OutlierScore: 15.3

Cost-per-claim above average for D0220 (Dental X-ray (Periapical, First Film))

PRESBYTERIAN HEALTHCARE SERVICES (1215913470) bills $226.58/claim for D0220 (Intraoral - periapical first image) vs avg $11.06 (+15.3σ). $715,537 across 3,158 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PRESBYTERIAN HEALTHCARE SERVICESALBUQUERQUEProvider total: $345.5M

criticalCost OutlierScore: 12.8

Cost-per-claim above average for 90837 (Psychotherapy (60 min))

ZUNI RECOVERY CENTER (1720406903) bills $674.02/claim for 90837 (Psytx w pt 60 minutes) vs avg $119.26 (+12.8σ). $235,232 across 349 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ZUNI RECOVERY CENTERZUNIProvider total: $286.5K

criticalCost OutlierScore: 12.7

Cost-per-claim above average for 90686 (Influenza Vaccine (Quadrivalent))

ALAMO NAVAJO SCHOOL BOARD, INC. (1861412777) bills $200.56/claim for 90686 (Iiv4 vacc no prsv 0.5 ml im) vs avg $7.60 (+12.7σ). $17,048 across 85 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALAMO NAVAJO SCHOOL BOARD, INC.ALAMOProvider total: $10.9M

criticalCost OutlierScore: 12.6

Cost-per-claim above average for S9999

SEQUEL OF NEW MEXICO, LLC (1992944557) bills $682.49/claim for S9999 (Sales tax) vs avg $15.32 (+12.6σ). $297,567 across 436 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

SEQUEL OF NEW MEXICO, LLCALBUQUERQUEProvider total: $4.2M

criticalCost OutlierScore: 12.3

Cost-per-claim above average for D0230 (Dental X-ray (Periapical, Each Additional))

LOVELACE HEALTH SYSTEM, LLC (1649373887) bills $146.82/claim for D0230 (Intraoral - periapical each addl image) vs avg $9.80 (+12.3σ). $203,492 across 1,386 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LOVELACE HEALTH SYSTEM, LLCALBUQUERQUEProvider total: $31.2M

criticalOverutilizationScore: 12.0

Unusually high claims-per-beneficiary ratio

OPTIHEALTH, INC. (1750427514): 43.5 claims/beneficiary (avg 2.6). 48,609 claims, 1,118 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

OPTIHEALTH, INC.ALBUQUERQUEProvider total: $7.3M

criticalCost OutlierScore: 11.7

Cost-per-claim above average for D0230 (Dental X-ray (Periapical, Each Additional))

PRESBYTERIAN HEALTHCARE SERVICES (1215913470) bills $139.60/claim for D0230 (Intraoral - periapical each addl image) vs avg $9.80 (+11.7σ). $642,599 across 4,603 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PRESBYTERIAN HEALTHCARE SERVICESALBUQUERQUEProvider total: $345.5M

criticalCost OutlierScore: 11.1

Cost-per-claim above average for 90471 (Immunization Administration (Injection))

DHHS,PHS,NAIHS, GALLUP INDIAN MEDICAL CENTER (1225002322) bills $493.44/claim for 90471 (Immunization admin) vs avg $22.07 (+11.1σ). $19,244 across 39 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DHHS,PHS,NAIHS, GALLUP INDIAN MEDICAL CENTERGALLUPProvider total: $32.7M

criticalCost OutlierScore: 11.0

Cost-per-claim above average for 90837 (Psychotherapy (60 min))

SANTO DOMINGO BEHAVIORAL HEALTH PROGRAM (1396944211) bills $594.37/claim for 90837 (Psytx w pt 60 minutes) vs avg $119.26 (+11.0σ). $44,578 across 75 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

SANTO DOMINGO BEHAVIORAL HEALTH PROGRAMSANTO DOMINGO PUEBLOProvider total: $234.9K

criticalCost OutlierScore: 10.7

Cost-per-claim above average for D1351 (Dental Sealant (per Tooth))

LAS CRUCES SURGERY CENTER LP (1861444838) bills $455.46/claim for D1351 (Sealant per tooth) vs avg $29.31 (+10.7σ). $79,705 across 175 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LAS CRUCES SURGERY CENTER LPLAS CRUCESProvider total: $9.2M

criticalCost OutlierScore: 10.7

Cost-per-claim above average for D0220 (Dental X-ray (Periapical, First Film))

LOVELACE HEALTH SYSTEM, LLC (1649373887) bills $161.20/claim for D0220 (Intraoral - periapical first image) vs avg $11.06 (+10.6σ). $542,439 across 3,365 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LOVELACE HEALTH SYSTEM, LLCALBUQUERQUEProvider total: $31.2M

criticalCost OutlierScore: 10.2

Cost-per-claim above average for 99213 (Office Visit, Established Patient (20 min, Low Complexity))

DHHS, PHS, NAIHS, SHIPROCK HOSPITAL (1083839476) bills $556.82/claim for 99213 (Office o/p est low 20 min) vs avg $67.95 (+10.2σ). $87,421 across 157 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DHHS, PHS, NAIHS, SHIPROCK HOSPITALSANOSTEEProvider total: $106.6K

criticalCost OutlierScore: 10.1

Cost-per-claim above average for 81003 (Urinalysis by Dipstick (Automated))

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC. (1932199171) bills $51.33/claim for 81003 (Urinalysis auto w/o scope) vs avg $2.65 (+10.0σ). $77,253 across 1,505 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC.ALBUQUERQUEProvider total: $15.4M

criticalCost OutlierScore: 9.7

Cost-per-claim above average for D0140 (Limited Oral Evaluation (Problem-Focused))

DHHS PHS NAIHS CROWNPOINT HOSPITAL (1114960093) bills $508.71/claim for D0140 (Limited oral evaluation - problem focused) vs avg $32.05 (+9.7σ). $15,770 across 31 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DHHS PHS NAIHS CROWNPOINT HOSPITALCROWNPOINTProvider total: $35.3M

criticalCost OutlierScore: 9.6

Cost-per-claim above average for D7140 (Tooth Extraction (Erupted Tooth, Simple))

LOVELACE HEALTH SYSTEM LLC (1972878361) bills $459.75/claim for D7140 (Extraction erupted tooth or exposed root) vs avg $67.83 (+9.6σ). $28,045 across 61 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LOVELACE HEALTH SYSTEM LLCROSWELLProvider total: $20.1M

criticalCost OutlierScore: 9.6

Cost-per-claim above average for 99213 (Office Visit, Established Patient (20 min, Low Complexity))

DHHS, PHS, NAIHS, SHIPROCK HOSPITAL (1780639971) bills $527.68/claim for 99213 (Office o/p est low 20 min) vs avg $67.95 (+9.6σ). $39,238,576 across 74,360 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DHHS, PHS, NAIHS, SHIPROCK HOSPITALSHIPROCKProvider total: $190.6M

criticalCost OutlierScore: 9.6

Cost-per-claim above average for D2391 (Dental Filling, Composite/Resin (One Surface, Posterior))

LOVELACE HEALTH SYSTEM LLC (1972878361) bills $554.01/claim for D2391 (Resin composite - one surface posterior) vs avg $57.77 (+9.6σ). $21,052 across 38 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LOVELACE HEALTH SYSTEM LLCROSWELLProvider total: $20.1M

criticalCost OutlierScore: 9.5

Cost-per-claim above average for 80305 (Drug Screening, Presumptive (Instrument-Based))

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC. (1932199171) bills $99.13/claim for 80305 (Drug test prsmv dir opt obs) vs avg $10.40 (+9.5σ). $408,234 across 4,118 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC.ALBUQUERQUEProvider total: $15.4M

criticalCost OutlierScore: 9.4

Cost-per-claim above average for J1100 (Dexamethasone Injection (1 mg))

LEA REGIONAL HOSPITAL LLC (1285688697) bills $42.42/claim for J1100 (Dexamethasone sodium phos) vs avg $1.84 (+9.4σ). $57,783 across 1,362 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LEA REGIONAL HOSPITAL LLCHOBBSProvider total: $10.6M

criticalCost OutlierScore: 9.3

Cost-per-claim above average for 90837 (Psychotherapy (60 min))

COURAGEOUS TRANSFORMATIONS, INC (1568838795) bills $523.52/claim for 90837 (Psytx w pt 60 minutes) vs avg $119.26 (+9.4σ). $29,317 across 56 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

COURAGEOUS TRANSFORMATIONS, INCALBUQUERQUEProvider total: $13.3M

criticalCost OutlierScore: 9.3

Cost-per-claim above average for D0272 (Dental X-rays (Bitewings, 2 Films))

LOVELACE HEALTH SYSTEM, LLC (1649373887) bills $211.94/claim for D0272 (Bitewings - two radiographic images) vs avg $21.41 (+9.3σ). $549,348 across 2,592 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LOVELACE HEALTH SYSTEM, LLCALBUQUERQUEProvider total: $31.2M

criticalCost OutlierScore: 9.2

Cost-per-claim above average for 85025 (Complete Blood Count (CBC) with Differential)

DE BACA FAMILY PRACTICE CLINIC (1003855032) bills $81.10/claim for 85025 (Complete cbc w/auto diff wbc) vs avg $6.56 (+9.2σ). $33,577 across 414 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DE BACA FAMILY PRACTICE CLINICFORT SUMNERProvider total: $2.3M

criticalCost OutlierScore: 9.1

Cost-per-claim above average for 36415 (Blood Draw (Venipuncture))

DEMING HOSPITAL CORPORATION (1134526221) bills $66.05/claim for 36415 (Coll venous bld venipuncture) vs avg $4.59 (+9.1σ). $27,147 across 411 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DEMING HOSPITAL CORPORATIONDEMINGProvider total: $11.4M

criticalCost OutlierScore: 9.1

Cost-per-claim above average for 81002 (Urinalysis without Microscopy)

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC. (1932199171) bills $70.40/claim for 81002 (Urinalysis nonauto w/o scope) vs avg $3.85 (+9.1σ). $144,395 across 2,051 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

FIRST NATIONS COMMUNITY HEALTH SOURCE, INC.ALBUQUERQUEProvider total: $15.4M

criticalOverutilizationScore: 8.8

Unusually high claims-per-beneficiary ratio

SWAN TRANS LLC (1346927209): 32.6 claims/beneficiary (avg 2.6). 3,190 claims, 98 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

SWAN TRANS LLCSANTA FEProvider total: $667.4K

criticalCost OutlierScore: 8.8

Cost-per-claim above average for 99213 (Office Visit, Established Patient (20 min, Low Complexity))

TAOS PICURIS HEALTH CENTER (1548372071) bills $488.36/claim for 99213 (Office o/p est low 20 min) vs avg $67.95 (+8.8σ). $2,815,867 across 5,766 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

TAOS PICURIS HEALTH CENTERTAOSProvider total: $6.6M

criticalCost OutlierScore: 8.6

Cost-per-claim above average for 87880 (Rapid Strep A Test (Optical/Immunoassay))

DE BACA FAMILY PRACTICE CLINIC (1699082644) bills $117.83/claim for 87880 (Strep a assay w/optic) vs avg $15.45 (+8.6σ). $66,221 across 562 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DE BACA FAMILY PRACTICE CLINICFORT SUMNERProvider total: $180.8K

criticalCost OutlierScore: 8.3

Cost-per-claim above average for 90834 (Psychotherapy (45 min))

ZUNI RECOVERY CENTER (1720406903) bills $654.00/claim for 90834 (Psytx w pt 45 minutes) vs avg $96.29 (+8.3σ). $10,464 across 16 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ZUNI RECOVERY CENTERZUNIProvider total: $286.5K

criticalOverutilizationScore: 8.3

Unusually high claims-per-beneficiary ratio

SOLANA CARE, LC (1588289334): 30.6 claims/beneficiary (avg 2.6). 7,785 claims, 254 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

SOLANA CARE, LCALBUQUERQUEProvider total: $2.9M

criticalCost OutlierScore: 8.2

Cost-per-claim above average for 99203 (Office Visit, New Patient (30 min, Low Complexity))

BETH RIECHES (1518266576) bills $396.58/claim for 99203 (Office o/p new low 30 min) vs avg $95.93 (+8.2σ). $46,400 across 117 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

BETH RIECHESMIMBRESProvider total: $154.2K

criticalCost OutlierScore: 8.0

Cost-per-claim above average for 82962

PRESBYTERIAN MEDICAL SERVICES (1093908246) bills $58.82/claim for 82962 (Glucose blood test) vs avg $4.17 (+8.0σ). $12,235 across 208 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PRESBYTERIAN MEDICAL SERVICESHOBBSProvider total: $1.1M

criticalCost OutlierScore: 7.7

Cost-per-claim above average for G0467

AMADOR HEALTH CENTER, INC. (1700178167) bills $159.58/claim for G0467 (Fqhc visit, estab pt) vs avg $24.76 (+7.7σ). $788,780 across 4,943 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

AMADOR HEALTH CENTER, INC.LAS CRUCESProvider total: $2.2M

criticalCost OutlierScore: 7.6

Cost-per-claim above average for 1036F

DEMING HOSPITAL CORPORATION (1134526221) bills $57.20/claim for 1036F vs avg $1.22 (+7.6σ). $14,357 across 251 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DEMING HOSPITAL CORPORATIONDEMINGProvider total: $11.4M

criticalCost OutlierScore: 7.5

Cost-per-claim above average for 90791 (Psychiatric Diagnostic Evaluation)

MESCALERO TRIBAL HUMAN SERVICES (1285834150) bills $491.37/claim for 90791 (Psych diagnostic evaluation) vs avg $137.83 (+7.5σ). $13,267 across 27 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

MESCALERO TRIBAL HUMAN SERVICESMESCALEROProvider total: $190.3K

criticalCost OutlierScore: 7.5

Cost-per-claim above average for 99204 (Office Visit, New Patient (45 min, Moderate Complexity))

BETH RIECHES (1518266576) bills $398.77/claim for 99204 (Office o/p new mod 45 min) vs avg $132.97 (+7.5σ). $105,675 across 265 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

BETH RIECHESMIMBRESProvider total: $154.2K

criticalCost OutlierScore: 7.4

Cost-per-claim above average for 99391 (Preventive Visit, Established Patient (Infant, <1 year))

SANTA FE INDIAN HOSPITAL (1285613836) bills $541.14/claim for 99391 (Per pm reeval est pat infant) vs avg $115.23 (+7.4σ). $303,578 across 561 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

SANTA FE INDIAN HOSPITALSANTA FEProvider total: $12.5M

criticalCost OutlierScore: 7.3

Cost-per-claim above average for 90837 (Psychotherapy (60 min))

EIGHT NORTHERN INDIAN PUEBLOS COUNCIL INC., (1437275393) bills $436.73/claim for 90837 (Psytx w pt 60 minutes) vs avg $119.26 (+7.3σ). $1,082,662 across 2,479 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

EIGHT NORTHERN INDIAN PUEBLOS COUNCIL INC.,OHKAY OWINGEHProvider total: $5.6M

criticalCost OutlierScore: 7.3

Cost-per-claim above average for 90837 (Psychotherapy (60 min))

FIVE SANDOVAL INDIAN PUEBLOS, INC. (1689896284) bills $432.54/claim for 90837 (Psytx w pt 60 minutes) vs avg $119.26 (+7.2σ). $88,671 across 205 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

FIVE SANDOVAL INDIAN PUEBLOS, INC.BERNALILLOProvider total: $3.2M

criticalCost OutlierScore: 7.2

Cost-per-claim above average for D2391 (Dental Filling, Composite/Resin (One Surface, Posterior))

LAS CRUCES SURGERY CENTER LP (1861444838) bills $433.48/claim for D2391 (Resin composite - one surface posterior) vs avg $57.77 (+7.2σ). $130,044 across 300 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LAS CRUCES SURGERY CENTER LPLAS CRUCESProvider total: $9.2M

criticalOverutilizationScore: 7.2

Unusually high claims-per-beneficiary ratio

FAMILYWORKS, INC (1255548905): 27.1 claims/beneficiary (avg 2.6). 11,807 claims, 435 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

FAMILYWORKS, INCALBUQUERQUEProvider total: $1.9M

criticalCost OutlierScore: 7.2

Cost-per-claim above average for 90670

SRICHAND DARA (1730284548) bills $294.22/claim for 90670 (Pcv13 vaccine im) vs avg $11.04 (+7.2σ). $31,188 across 106 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

SRICHAND DARACARLSBADProvider total: $725.8K

criticalCost OutlierScore: 7.1

Cost-per-claim above average for 99392 (Preventive Visit, Established Patient (Ages 1-4))

SANTA FE INDIAN HOSPITAL (1285613836) bills $626.89/claim for 99392 (Prev visit est age 1-4) vs avg $118.85 (+7.1σ). $569,843 across 909 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

SANTA FE INDIAN HOSPITALSANTA FEProvider total: $12.5M

criticalCost OutlierScore: 7.1

Cost-per-claim above average for 92340

FAMILY EYE CARE/CHILDREN'S EYE CENTER OF NEW MEXICO, P.C. (1578574828) bills $143.39/claim for 92340 (Fit spectacles monofocal) vs avg $23.01 (+7.1σ). $3,055,971 across 21,313 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

FAMILY EYE CARE/CHILDREN'S EYE CENTER OF NEW MEXICO, P.C.ALBUQUERQUEProvider total: $13.3M

criticalCost OutlierScore: 7.0

Cost-per-claim above average for 97140 (Manual Therapy (per 15 min))

GROBECKER THERAPY INC. (1235267345) bills $134.96/claim for 97140 (Manual therapy 1/> regions) vs avg $31.88 (+7.0σ). $627,438 across 4,649 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

GROBECKER THERAPY INC.ALBUQUERQUEProvider total: $627.4K

criticalOverutilizationScore: 7.0

Unusually high claims-per-beneficiary ratio

ABOVE & BEYOND, INC. (1386787356): 26.3 claims/beneficiary (avg 2.6). 50,802 claims, 1,935 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

ABOVE & BEYOND, INC.ALBUQUERQUEProvider total: $19.2M

criticalOverutilizationScore: 6.9

Unusually high claims-per-beneficiary ratio

LEGACY HEALTHCARE INC. (1881024826): 26.0 claims/beneficiary (avg 2.6). 31,634 claims, 1,218 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

LEGACY HEALTHCARE INC.ALBUQUERQUEProvider total: $6.9M

criticalOverutilizationScore: 6.9

Unusually high claims-per-beneficiary ratio

WHEATFIELDS SENIOR LIVING (1154683654): 26.0 claims/beneficiary (avg 2.6). 9,394 claims, 362 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

WHEATFIELDS SENIOR LIVINGCLOVISProvider total: $649.6K

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Statistical Outliers

Single-test outliers in New Mexico Medicaid data. These are individual statistical flags — most are informational.