|
TETROFOSMIN DIAGNOSTIC PER STUDY DOSE
|
Facility
|
OP
|
$673.80
|
|
|
Service Code
|
CPT A9502
|
| Hospital Charge Code |
259502
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$168.45 |
| Max. Negotiated Rate |
$640.11 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$404.28
|
| Rate for Payer: Cash Price |
$404.28
|
| Rate for Payer: Cigna Commercial |
$572.73
|
| Rate for Payer: First Health Commercial |
$606.42
|
| Rate for Payer: First Health Workers Compensation |
$260.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$606.42
|
| Rate for Payer: GEHA Commercial |
$539.04
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$606.42
|
| Rate for Payer: Humana ChoiceCare |
$175.19
|
| Rate for Payer: Multiplan All |
$613.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$404.28
|
| Rate for Payer: OMNI Networks Commercial |
$471.66
|
| Rate for Payer: One Health Plan PPO/POS |
$606.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$640.11
|
| Rate for Payer: Three Rivers Provider Network All |
$505.35
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$592.94
|
| Rate for Payer: United Healthcare Managed Medicaid |
$168.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$626.63
|
| Rate for Payer: Zelis Auto |
$269.52
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$336.90
|
| Rate for Payer: Zelis Worker's Compensation |
$183.95
|
|
|
TETROFOSMIN DIAGNOSTIC PER STUDY DOSE
|
Facility
|
IP
|
$673.80
|
|
|
Service Code
|
CPT A9502
|
| Hospital Charge Code |
259502
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$183.95 |
| Max. Negotiated Rate |
$640.11 |
| Rate for Payer: Cash Price |
$404.28
|
| Rate for Payer: Cigna Commercial |
$572.73
|
| Rate for Payer: First Health Commercial |
$606.42
|
| Rate for Payer: First Health Workers Compensation |
$260.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$606.42
|
| Rate for Payer: GEHA Commercial |
$471.66
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$606.42
|
| Rate for Payer: Multiplan All |
$613.16
|
| Rate for Payer: OMNI Networks Commercial |
$471.66
|
| Rate for Payer: One Health Plan PPO/POS |
$606.42
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$640.11
|
| Rate for Payer: Three Rivers Provider Network All |
$505.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$626.63
|
| Rate for Payer: Zelis Auto |
$269.52
|
| Rate for Payer: Zelis Worker's Compensation |
$183.95
|
|
|
TET TOX-DIPH-ACELL PERTUSS 0.5ML IM
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3300879
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.79 |
| 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: 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 |
$43.79
|
| 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
|
|
|
TET TOX-DIPH-ACELL PERTUSS 0.5ML IM
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
3300879
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
thallium serum/plasma REF811687
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT 83018
|
| Hospital Charge Code |
2200684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.46 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: First Health Workers Compensation |
$40.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$133.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Worker's Compensation |
$28.46
|
|
|
thallium serum/plasma REF811687
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 83018
|
| Hospital Charge Code |
2200684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.52
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$31.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$21.96
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: First Health Workers Compensation |
$40.25
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$152.80
|
| Rate for Payer: GEHA Medicare |
$21.96
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Humana ChoiceCare |
$24.16
|
| Rate for Payer: Humana Medicare Advantage |
$21.96
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$36.89
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$21.96
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$37.33
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$36.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.95
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$21.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$43.92
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$21.52
|
| Rate for Payer: United Healthcare Commercial |
$162.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$21.96
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Medicare |
$18.67
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.35
|
| Rate for Payer: Zelis Worker's Compensation |
$28.46
|
|
|
thc serum screen w/ rflx REF700834
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200515
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$250.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$88.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$62.14
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$74.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$333.60
|
| Rate for Payer: GEHA Medicare |
$62.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Humana ChoiceCare |
$68.35
|
| Rate for Payer: Humana Medicare Advantage |
$62.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$104.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$90.42
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$62.14
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$105.64
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$104.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$90.42
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$62.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$124.28
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$60.90
|
| Rate for Payer: United Healthcare Commercial |
$354.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$62.14
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Medicare |
$52.82
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$74.57
|
| Rate for Payer: Zelis Worker's Compensation |
$52.63
|
|
|
thc serum screen w/ rflx REF700834
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
2200515
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.63 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$354.45
|
| Rate for Payer: First Health Commercial |
$375.30
|
| Rate for Payer: First Health Workers Compensation |
$74.43
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$375.30
|
| Rate for Payer: GEHA Commercial |
$291.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$375.30
|
| Rate for Payer: Multiplan All |
$379.47
|
| Rate for Payer: OMNI Networks Commercial |
$291.90
|
| Rate for Payer: One Health Plan PPO/POS |
$375.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$396.15
|
| Rate for Payer: Three Rivers Provider Network All |
$312.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$387.81
|
| Rate for Payer: Zelis Auto |
$166.80
|
| Rate for Payer: Zelis Worker's Compensation |
$52.63
|
|
|
THEOPHYLLINE TAB SR 12HR 200MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
3300884
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
THEOPHYLLINE TAB SR 12HR 200MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
3300884
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
THEOPHYLLINE TAB SR 12HR 300MG
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
3300885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$4.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
THEOPHYLLINE TAB SR 12HR 300MG
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
3300885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: First Health Commercial |
$6.30
|
| Rate for Payer: First Health Workers Compensation |
$2.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6.30
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6.30
|
| Rate for Payer: Humana ChoiceCare |
$1.82
|
| Rate for Payer: Multiplan All |
$6.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.20
|
| Rate for Payer: OMNI Networks Commercial |
$4.90
|
| Rate for Payer: One Health Plan PPO/POS |
$6.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6.65
|
| Rate for Payer: Three Rivers Provider Network All |
$5.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6.51
|
| Rate for Payer: Zelis Auto |
$2.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1.91
|
|
|
THEOPHYLLINE(Vitros)
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
2232228
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$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 |
$24.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| 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: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$17.55
|
|
|
THEOPHYLLINE(Vitros)
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
2232228
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.02 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$25.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$25.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$20.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$14.14
|
| Rate for Payer: Cash Price |
$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 |
$24.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: GEHA Medicare |
$14.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare Advantage |
$14.14
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$23.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$20.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$14.14
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$24.04
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$23.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$20.58
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$14.14
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$28.28
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13.86
|
| Rate for Payer: United Healthcare Commercial |
$64.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$20.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$14.14
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Medicare |
$12.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$16.97
|
| Rate for Payer: Zelis Worker's Compensation |
$17.55
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
24500012
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
24700012
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
24700012
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$87.62 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$43.81
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$48.19
|
| Rate for Payer: Humana Medicare Advantage |
$43.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$73.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$41.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
21600136
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$87.62 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$43.81
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$48.19
|
| Rate for Payer: Humana Medicare Advantage |
$43.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$73.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
21600136
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$34.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW D
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
24500012
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$87.62 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$44.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$43.81
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$41.65
|
| Rate for Payer: First Health Commercial |
$44.10
|
| Rate for Payer: First Health Workers Compensation |
$18.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$44.10
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$44.10
|
| Rate for Payer: Humana ChoiceCare |
$48.19
|
| Rate for Payer: Humana Medicare Advantage |
$43.81
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$73.60
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$45.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$44.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$34.30
|
| Rate for Payer: One Health Plan PPO/POS |
$44.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$52.42
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$45.40
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$36.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$41.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45.57
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$19.60
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$13.38
|
|
|
THERAPEUTIC PROPH/DX INJECTION SUBQ/IM
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
20396372
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.96 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$164.90
|
| Rate for Payer: First Health Commercial |
$174.60
|
| Rate for Payer: First Health Workers Compensation |
$74.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$174.60
|
| Rate for Payer: GEHA Commercial |
$135.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$174.60
|
| Rate for Payer: Multiplan All |
$176.54
|
| Rate for Payer: OMNI Networks Commercial |
$135.80
|
| Rate for Payer: One Health Plan PPO/POS |
$174.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$184.30
|
| Rate for Payer: Three Rivers Provider Network All |
$145.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$180.42
|
| Rate for Payer: Zelis Auto |
$77.60
|
| Rate for Payer: Zelis Worker's Compensation |
$52.96
|
|
|
THERAPEUTIC PROPH/DX INJECTION SUBQ/IM
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
20396372
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$116.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$67.58
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$164.90
|
| Rate for Payer: First Health Commercial |
$174.60
|
| Rate for Payer: First Health Workers Compensation |
$74.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$174.60
|
| Rate for Payer: GEHA Commercial |
$155.20
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$174.60
|
| Rate for Payer: Humana ChoiceCare |
$74.34
|
| Rate for Payer: Humana Medicare Advantage |
$67.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$113.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$176.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$135.80
|
| Rate for Payer: One Health Plan PPO/POS |
$174.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$184.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$145.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$180.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$77.60
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$52.96
|
|
|
THERAPEUTIC PROPHYLACTIC/DX INJECTION SQ
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
9396372
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$52.96 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$164.90
|
| Rate for Payer: First Health Commercial |
$174.60
|
| Rate for Payer: First Health Workers Compensation |
$74.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$174.60
|
| Rate for Payer: GEHA Commercial |
$135.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$174.60
|
| Rate for Payer: Multiplan All |
$176.54
|
| Rate for Payer: OMNI Networks Commercial |
$135.80
|
| Rate for Payer: One Health Plan PPO/POS |
$174.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$184.30
|
| Rate for Payer: Three Rivers Provider Network All |
$145.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$180.42
|
| Rate for Payer: Zelis Auto |
$77.60
|
| Rate for Payer: Zelis Worker's Compensation |
$52.96
|
|
|
THERAPEUTIC PROPHYLACTIC/DX INJECTION SQ
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
21600047
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$52.96 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$164.90
|
| Rate for Payer: First Health Commercial |
$174.60
|
| Rate for Payer: First Health Workers Compensation |
$74.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$174.60
|
| Rate for Payer: GEHA Commercial |
$135.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$174.60
|
| Rate for Payer: Multiplan All |
$176.54
|
| Rate for Payer: OMNI Networks Commercial |
$135.80
|
| Rate for Payer: One Health Plan PPO/POS |
$174.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$184.30
|
| Rate for Payer: Three Rivers Provider Network All |
$145.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$180.42
|
| Rate for Payer: Zelis Auto |
$77.60
|
| Rate for Payer: Zelis Worker's Compensation |
$52.96
|
|
|
THERAPEUTIC PROPHYLACTIC/DX INJECTION SQ
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
21696372
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$116.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$67.58
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$164.90
|
| Rate for Payer: First Health Commercial |
$174.60
|
| Rate for Payer: First Health Workers Compensation |
$74.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$174.60
|
| Rate for Payer: GEHA Commercial |
$155.20
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$174.60
|
| Rate for Payer: Humana ChoiceCare |
$74.34
|
| Rate for Payer: Humana Medicare Advantage |
$67.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$113.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$176.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$135.80
|
| Rate for Payer: One Health Plan PPO/POS |
$174.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$184.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$145.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$180.42
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$77.60
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$52.96
|
|
