|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
8500018
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21900207
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21500023
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21000016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
24599242
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21000016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21900207
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$61.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMD OFF/OTHR OP CONS NEW/ESTAB; 20 M>
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
21500023
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
TELMED OFFICE VISIT LEVEL 1 LOW COMP
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT 99201
|
| Hospital Charge Code |
8700012
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$37.13 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$115.60
|
| Rate for Payer: First Health Commercial |
$122.40
|
| Rate for Payer: First Health Workers Compensation |
$52.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$122.40
|
| Rate for Payer: GEHA Commercial |
$95.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$122.40
|
| Rate for Payer: Multiplan All |
$123.76
|
| Rate for Payer: OMNI Networks Commercial |
$95.20
|
| Rate for Payer: One Health Plan PPO/POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$129.20
|
| Rate for Payer: Three Rivers Provider Network All |
$102.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$126.48
|
| Rate for Payer: Zelis Auto |
$54.40
|
| Rate for Payer: Zelis Worker's Compensation |
$37.13
|
|
|
TELMED OFFICE VISIT LEVEL 1 LOW COMP
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT 99201
|
| Hospital Charge Code |
8700012
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$115.60
|
| Rate for Payer: First Health Commercial |
$122.40
|
| Rate for Payer: First Health Workers Compensation |
$52.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$122.40
|
| Rate for Payer: GEHA Commercial |
$108.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$122.40
|
| Rate for Payer: Humana ChoiceCare |
$35.36
|
| Rate for Payer: Multiplan All |
$123.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$81.60
|
| Rate for Payer: OMNI Networks Commercial |
$95.20
|
| Rate for Payer: One Health Plan PPO/POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$129.20
|
| Rate for Payer: Three Rivers Provider Network All |
$102.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$126.48
|
| Rate for Payer: Zelis Auto |
$54.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.00
|
| Rate for Payer: Zelis Worker's Compensation |
$37.13
|
|
|
TEMAZEPAM 15MG CAP
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
3300872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$8.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Humana ChoiceCare |
$2.60
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6.00
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
TEMAZEPAM 15MG CAP
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
3300872
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$8.50
|
| Rate for Payer: First Health Commercial |
$9.00
|
| Rate for Payer: First Health Workers Compensation |
$3.86
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9.00
|
| Rate for Payer: GEHA Commercial |
$7.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9.00
|
| Rate for Payer: Multiplan All |
$9.10
|
| Rate for Payer: OMNI Networks Commercial |
$7.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9.50
|
| Rate for Payer: Three Rivers Provider Network All |
$7.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9.30
|
| Rate for Payer: Zelis Auto |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.73
|
|
|
TEMPORAL ARTERY PROCEDURE
|
Facility
|
OP
|
$909.09
|
|
|
Service Code
|
CPT 37609
|
| Hospital Charge Code |
6137609
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$248.18 |
| Max. Negotiated Rate |
$3,076.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$545.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,769.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,401.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,538.48
|
| Rate for Payer: Cash Price |
$545.45
|
| Rate for Payer: Cash Price |
$545.45
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$818.18
|
| Rate for Payer: First Health Workers Compensation |
$351.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$818.18
|
| Rate for Payer: GEHA Commercial |
$727.27
|
| Rate for Payer: GEHA Medicare |
$1,538.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$818.18
|
| Rate for Payer: Humana ChoiceCare |
$1,692.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,538.48
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,584.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,430.07
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,538.48
|
| Rate for Payer: Multiplan All |
$827.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,615.42
|
| Rate for Payer: OMNI Networks Commercial |
$636.36
|
| Rate for Payer: One Health Plan PPO/POS |
$818.18
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,651.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,430.07
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,538.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$863.64
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,076.96
|
| Rate for Payer: Three Rivers Provider Network All |
$681.82
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,507.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,430.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,538.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$845.45
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,538.48
|
| Rate for Payer: Zelis Auto |
$363.64
|
| Rate for Payer: Zelis Medicare |
$1,307.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,846.18
|
| Rate for Payer: Zelis Worker's Compensation |
$248.18
|
|
|
TEMPORAL ARTERY PROCEDURE
|
Facility
|
IP
|
$909.09
|
|
|
Service Code
|
CPT 37609
|
| Hospital Charge Code |
6137609
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$248.18 |
| Max. Negotiated Rate |
$863.64 |
| Rate for Payer: Cash Price |
$545.45
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$818.18
|
| Rate for Payer: First Health Workers Compensation |
$351.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$818.18
|
| Rate for Payer: GEHA Commercial |
$636.36
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$818.18
|
| Rate for Payer: Multiplan All |
$827.27
|
| Rate for Payer: OMNI Networks Commercial |
$636.36
|
| Rate for Payer: One Health Plan PPO/POS |
$818.18
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$863.64
|
| Rate for Payer: Three Rivers Provider Network All |
$681.82
|
| Rate for Payer: United Payors & United Providers UP&UP |
$845.45
|
| Rate for Payer: Zelis Auto |
$363.64
|
| Rate for Payer: Zelis Worker's Compensation |
$248.18
|
|
|
TENDON EXCISION PALM/FINGER
|
Facility
|
OP
|
$1,037.00
|
|
|
Service Code
|
CPT 26145
|
| Hospital Charge Code |
6126145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$283.10 |
| Max. Negotiated Rate |
$3,039.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$622.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,519.65
|
| Rate for Payer: Cash Price |
$622.20
|
| Rate for Payer: Cash Price |
$622.20
|
| Rate for Payer: Cigna Commercial |
$881.45
|
| Rate for Payer: First Health Commercial |
$933.30
|
| Rate for Payer: First Health Workers Compensation |
$400.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$933.30
|
| Rate for Payer: GEHA Commercial |
$829.60
|
| Rate for Payer: GEHA Medicare |
$1,519.65
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$933.30
|
| Rate for Payer: Humana ChoiceCare |
$1,671.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,519.65
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,553.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,519.65
|
| Rate for Payer: Multiplan All |
$943.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,583.41
|
| Rate for Payer: OMNI Networks Commercial |
$725.90
|
| Rate for Payer: One Health Plan PPO/POS |
$933.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,519.65
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$985.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,039.30
|
| Rate for Payer: Three Rivers Provider Network All |
$777.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,489.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,519.65
|
| Rate for Payer: United Payors & United Providers UP&UP |
$964.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,519.65
|
| Rate for Payer: Zelis Auto |
$414.80
|
| Rate for Payer: Zelis Medicare |
$1,291.70
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,823.58
|
| Rate for Payer: Zelis Worker's Compensation |
$283.10
|
|
|
TENDON EXCISION PALM/FINGER
|
Facility
|
IP
|
$1,037.00
|
|
|
Service Code
|
CPT 26145
|
| Hospital Charge Code |
6126145
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$283.10 |
| Max. Negotiated Rate |
$985.15 |
| Rate for Payer: Cash Price |
$622.20
|
| Rate for Payer: Cigna Commercial |
$881.45
|
| Rate for Payer: First Health Commercial |
$933.30
|
| Rate for Payer: First Health Workers Compensation |
$400.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$933.30
|
| Rate for Payer: GEHA Commercial |
$725.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$933.30
|
| Rate for Payer: Multiplan All |
$943.67
|
| Rate for Payer: OMNI Networks Commercial |
$725.90
|
| Rate for Payer: One Health Plan PPO/POS |
$933.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$985.15
|
| Rate for Payer: Three Rivers Provider Network All |
$777.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$964.41
|
| Rate for Payer: Zelis Auto |
$414.80
|
| Rate for Payer: Zelis Worker's Compensation |
$283.10
|
|
|
TENDON LENGTHENING
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
CPT 26476
|
| Hospital Charge Code |
6126476
|
|
Hospital Revenue Code
|
975
|
| 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
|
|
|
TENDON LENGTHENING
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
CPT 26476
|
| Hospital Charge Code |
6126476
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$309.31 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| 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 |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| 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 |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,019.70
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,031.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| 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 |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,076.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$849.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,053.69
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$453.20
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$309.31
|
|
|
TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)
|
Facility
|
OP
|
$3,039.30
|
|
|
Service Code
|
CPT 26055
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,291.70 |
| Max. Negotiated Rate |
$3,039.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,519.65
|
| Rate for Payer: First Health Workers Compensation |
$1,955.79
|
| Rate for Payer: GEHA Medicare |
$1,519.65
|
| Rate for Payer: Humana ChoiceCare |
$1,671.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,519.65
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,553.01
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,519.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,583.41
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,519.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,039.30
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,489.26
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,519.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,519.65
|
| Rate for Payer: Zelis Medicare |
$1,291.70
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,823.58
|
| Rate for Payer: Zelis Worker's Compensation |
$1,382.88
|
|
|
TENDON SHORTENING
|
Facility
|
OP
|
$1,139.00
|
|
|
Service Code
|
CPT 26477
|
| Hospital Charge Code |
6126477
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$310.95 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$683.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,723.10
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,365.04
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$683.40
|
| Rate for Payer: Cash Price |
$683.40
|
| Rate for Payer: Cigna Commercial |
$968.15
|
| Rate for Payer: First Health Commercial |
$1,025.10
|
| Rate for Payer: First Health Workers Compensation |
$439.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,025.10
|
| Rate for Payer: GEHA Commercial |
$911.20
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,025.10
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,392.84
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,036.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$797.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,025.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,608.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,392.84
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,082.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$854.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,392.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,059.27
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$455.60
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$310.95
|
|
|
TENDON SHORTENING
|
Facility
|
IP
|
$1,139.00
|
|
|
Service Code
|
CPT 26477
|
| Hospital Charge Code |
6126477
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$310.95 |
| Max. Negotiated Rate |
$1,082.05 |
| Rate for Payer: Cash Price |
$683.40
|
| Rate for Payer: Cigna Commercial |
$968.15
|
| Rate for Payer: First Health Commercial |
$1,025.10
|
| Rate for Payer: First Health Workers Compensation |
$439.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,025.10
|
| Rate for Payer: GEHA Commercial |
$797.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,025.10
|
| Rate for Payer: Multiplan All |
$1,036.49
|
| Rate for Payer: OMNI Networks Commercial |
$797.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,025.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,082.05
|
| Rate for Payer: Three Rivers Provider Network All |
$854.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,059.27
|
| Rate for Payer: Zelis Auto |
$455.60
|
| Rate for Payer: Zelis Worker's Compensation |
$310.95
|
|
|
TENDON TRANSFER WITH GRAFT
|
Facility
|
OP
|
$1,730.00
|
|
|
Service Code
|
CPT 26492
|
| Hospital Charge Code |
6126492
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$472.29 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,038.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,855.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,261.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: Cash Price |
$1,038.00
|
| Rate for Payer: Cash Price |
$1,038.00
|
| Rate for Payer: Cigna Commercial |
$1,470.50
|
| Rate for Payer: First Health Commercial |
$1,557.00
|
| Rate for Payer: First Health Workers Compensation |
$667.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,557.00
|
| Rate for Payer: GEHA Commercial |
$1,384.00
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,557.00
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,307.85
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: Multiplan All |
$1,574.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: OMNI Networks Commercial |
$1,211.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,557.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,664.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,307.85
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,643.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: Three Rivers Provider Network All |
$1,297.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,307.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,608.90
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Auto |
$692.00
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$472.29
|
|
|
TENDON TRANSFER WITH GRAFT
|
Facility
|
IP
|
$1,730.00
|
|
|
Service Code
|
CPT 26492
|
| Hospital Charge Code |
6126492
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$472.29 |
| Max. Negotiated Rate |
$1,643.50 |
| Rate for Payer: Cash Price |
$1,038.00
|
| Rate for Payer: Cigna Commercial |
$1,470.50
|
| Rate for Payer: First Health Commercial |
$1,557.00
|
| Rate for Payer: First Health Workers Compensation |
$667.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,557.00
|
| Rate for Payer: GEHA Commercial |
$1,211.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,557.00
|
| Rate for Payer: Multiplan All |
$1,574.30
|
| Rate for Payer: OMNI Networks Commercial |
$1,211.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,557.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,643.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,297.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,608.90
|
| Rate for Payer: Zelis Auto |
$692.00
|
| Rate for Payer: Zelis Worker's Compensation |
$472.29
|
|
|
TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON
|
Facility
|
OP
|
$6,161.78
|
|
|
Service Code
|
CPT 25310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,618.76 |
| Max. Negotiated Rate |
$6,161.78 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$4,709.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$4,709.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$3,730.88
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,080.89
|
| Rate for Payer: First Health Workers Compensation |
$3,965.11
|
| Rate for Payer: GEHA Medicare |
$3,080.89
|
| Rate for Payer: Humana ChoiceCare |
$3,388.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,080.89
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,175.90
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$3,806.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,080.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,237.51
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$4,395.55
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$3,806.86
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,080.89
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,161.78
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,019.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,806.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,080.89
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,080.89
|
| Rate for Payer: Zelis Medicare |
$2,618.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,697.07
|
| Rate for Payer: Zelis Worker's Compensation |
$2,803.61
|
|
|
TENECTEPLASE (ACUTE MI) 50MG KIT
|
Facility
|
IP
|
$23,860.00
|
|
|
Service Code
|
CPT J3101
|
| Hospital Charge Code |
3300873
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,513.78 |
| Max. Negotiated Rate |
$22,667.00 |
| Rate for Payer: Cash Price |
$14,316.00
|
| Rate for Payer: Cigna Commercial |
$20,281.00
|
| Rate for Payer: First Health Commercial |
$21,474.00
|
| Rate for Payer: First Health Workers Compensation |
$9,212.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$21,474.00
|
| Rate for Payer: GEHA Commercial |
$16,702.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$21,474.00
|
| Rate for Payer: Multiplan All |
$21,712.60
|
| Rate for Payer: OMNI Networks Commercial |
$16,702.00
|
| Rate for Payer: One Health Plan PPO/POS |
$21,474.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$22,667.00
|
| Rate for Payer: Three Rivers Provider Network All |
$17,895.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$22,189.80
|
| Rate for Payer: Zelis Auto |
$9,544.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6,513.78
|
|
