|
THERAPEUTIC PROPHYLACTIC/DX INJECTION SU
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8499251
|
|
Hospital Revenue Code
|
513
|
| 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: 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 |
$80.00
|
| 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 SU
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
24700015
|
|
Hospital Revenue Code
|
260
|
| 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 SU
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
24700015
|
|
Hospital Revenue Code
|
260
|
| 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 Commercial |
$164.90
|
| 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 SU
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
1996372
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna Commercial |
$221.00
|
| Rate for Payer: First Health Commercial |
$234.00
|
| Rate for Payer: First Health Workers Compensation |
$100.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$234.00
|
| Rate for Payer: GEHA Commercial |
$182.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$234.00
|
| Rate for Payer: Multiplan All |
$236.60
|
| Rate for Payer: OMNI Networks Commercial |
$182.00
|
| Rate for Payer: One Health Plan PPO/POS |
$234.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$247.00
|
| Rate for Payer: Three Rivers Provider Network All |
$195.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$241.80
|
| Rate for Payer: Zelis Auto |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$70.98
|
|
|
THERAPEUTIC PROPHYLACTIC/DX INJ SUBQ/IM
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8296372
|
|
Hospital Revenue Code
|
519
|
| 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 INJ SUBQ/IM
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8296372
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
THERAP REPETITIVE TMS TX SUBSEQ DELIVERY
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
CPT 90868
|
| Hospital Charge Code |
9599242
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$143.87 |
| Max. Negotiated Rate |
$500.65 |
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cigna Commercial |
$447.95
|
| Rate for Payer: First Health Commercial |
$474.30
|
| Rate for Payer: First Health Workers Compensation |
$203.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$474.30
|
| Rate for Payer: GEHA Commercial |
$368.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$474.30
|
| Rate for Payer: Multiplan All |
$479.57
|
| Rate for Payer: OMNI Networks Commercial |
$368.90
|
| Rate for Payer: One Health Plan PPO/POS |
$474.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$500.65
|
| Rate for Payer: Three Rivers Provider Network All |
$395.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$490.11
|
| Rate for Payer: Zelis Auto |
$210.80
|
| Rate for Payer: Zelis Worker's Compensation |
$143.87
|
|
|
THERAP REPETITIVE TMS TX SUBSEQ DELIVERY
|
Facility
|
OP
|
$527.00
|
|
|
Service Code
|
CPT 90868
|
| Hospital Charge Code |
9599242
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$143.87 |
| Max. Negotiated Rate |
$591.38 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$273.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$316.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$273.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$216.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$295.69
|
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cash Price |
$316.20
|
| Rate for Payer: Cigna Commercial |
$447.95
|
| Rate for Payer: First Health Commercial |
$474.30
|
| Rate for Payer: First Health Workers Compensation |
$203.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$474.30
|
| Rate for Payer: GEHA Commercial |
$421.60
|
| Rate for Payer: GEHA Medicare |
$295.69
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$474.30
|
| Rate for Payer: Humana ChoiceCare |
$325.26
|
| Rate for Payer: Humana Medicare Advantage |
$295.69
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$496.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$220.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$295.69
|
| Rate for Payer: Multiplan All |
$479.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$502.67
|
| Rate for Payer: OMNI Networks Commercial |
$368.90
|
| Rate for Payer: One Health Plan PPO/POS |
$474.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$255.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$220.92
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$295.69
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$500.65
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$591.38
|
| Rate for Payer: Three Rivers Provider Network All |
$395.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$289.78
|
| Rate for Payer: United Healthcare Managed Medicaid |
$220.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.69
|
| Rate for Payer: United Payors & United Providers UP&UP |
$490.11
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$295.69
|
| Rate for Payer: Zelis Auto |
$210.80
|
| Rate for Payer: Zelis Medicare |
$251.34
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$354.83
|
| Rate for Payer: Zelis Worker's Compensation |
$143.87
|
|
|
THERAPY FOR CONTOUR DEFECTS
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
CPT 11954
|
| Hospital Charge Code |
6111954
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$1,162.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$212.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$581.24
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$300.90
|
| Rate for Payer: First Health Commercial |
$318.60
|
| Rate for Payer: First Health Workers Compensation |
$136.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$318.60
|
| Rate for Payer: GEHA Commercial |
$283.20
|
| Rate for Payer: GEHA Medicare |
$581.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$318.60
|
| Rate for Payer: Humana ChoiceCare |
$639.36
|
| Rate for Payer: Humana Medicare Advantage |
$581.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$976.48
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$581.24
|
| Rate for Payer: Multiplan All |
$322.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$988.11
|
| Rate for Payer: OMNI Networks Commercial |
$247.80
|
| Rate for Payer: One Health Plan PPO/POS |
$318.60
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$581.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$336.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,162.48
|
| Rate for Payer: Three Rivers Provider Network All |
$265.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$569.62
|
| Rate for Payer: United Healthcare Managed Medicaid |
$88.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$581.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$329.22
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$581.24
|
| Rate for Payer: Zelis Auto |
$141.60
|
| Rate for Payer: Zelis Medicare |
$494.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$697.49
|
| Rate for Payer: Zelis Worker's Compensation |
$96.64
|
|
|
THERAPY FOR CONTOUR DEFECTS
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
CPT 11954
|
| Hospital Charge Code |
6111954
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$96.64 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$300.90
|
| Rate for Payer: First Health Commercial |
$318.60
|
| Rate for Payer: First Health Workers Compensation |
$136.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$318.60
|
| Rate for Payer: GEHA Commercial |
$247.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$318.60
|
| Rate for Payer: Multiplan All |
$322.14
|
| Rate for Payer: OMNI Networks Commercial |
$247.80
|
| Rate for Payer: One Health Plan PPO/POS |
$318.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$336.30
|
| Rate for Payer: Three Rivers Provider Network All |
$265.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$329.22
|
| Rate for Payer: Zelis Auto |
$141.60
|
| Rate for Payer: Zelis Worker's Compensation |
$96.64
|
|
|
THERASKIN
|
Facility
|
IP
|
$9,157.62
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,500.03 |
| Max. Negotiated Rate |
$8,699.74 |
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cigna Commercial |
$7,783.98
|
| Rate for Payer: First Health Commercial |
$8,241.86
|
| Rate for Payer: First Health Workers Compensation |
$3,535.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,241.86
|
| Rate for Payer: GEHA Commercial |
$6,410.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,241.86
|
| Rate for Payer: Multiplan All |
$8,333.43
|
| Rate for Payer: OMNI Networks Commercial |
$6,410.33
|
| Rate for Payer: One Health Plan PPO/POS |
$8,241.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,699.74
|
| Rate for Payer: Three Rivers Provider Network All |
$6,868.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,516.59
|
| Rate for Payer: Zelis Auto |
$3,663.05
|
| Rate for Payer: Zelis Worker's Compensation |
$2,500.03
|
|
|
THERASKIN
|
Facility
|
OP
|
$9,157.62
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006787
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$8,699.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,494.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cigna Commercial |
$7,783.98
|
| Rate for Payer: First Health Commercial |
$8,241.86
|
| Rate for Payer: First Health Workers Compensation |
$3,535.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,241.86
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,241.86
|
| Rate for Payer: Humana ChoiceCare |
$2,380.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$8,333.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,494.57
|
| Rate for Payer: OMNI Networks Commercial |
$6,410.33
|
| Rate for Payer: One Health Plan PPO/POS |
$8,241.86
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,699.74
|
| Rate for Payer: Three Rivers Provider Network All |
$6,868.22
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,058.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,516.59
|
| Rate for Payer: Zelis Auto |
$3,663.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,578.81
|
| Rate for Payer: Zelis Worker's Compensation |
$2,500.03
|
|
|
THERASKIN 1.75 X1.75
|
Facility
|
OP
|
$9,157.62
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006792
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$8,699.74 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,494.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cigna Commercial |
$7,783.98
|
| Rate for Payer: First Health Commercial |
$8,241.86
|
| Rate for Payer: First Health Workers Compensation |
$3,535.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,241.86
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,241.86
|
| Rate for Payer: Humana ChoiceCare |
$2,380.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$8,333.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,494.57
|
| Rate for Payer: OMNI Networks Commercial |
$6,410.33
|
| Rate for Payer: One Health Plan PPO/POS |
$8,241.86
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,699.74
|
| Rate for Payer: Three Rivers Provider Network All |
$6,868.22
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,058.71
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,516.59
|
| Rate for Payer: Zelis Auto |
$3,663.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,578.81
|
| Rate for Payer: Zelis Worker's Compensation |
$2,500.03
|
|
|
THERASKIN 1.75 X1.75
|
Facility
|
IP
|
$9,157.62
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006792
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,500.03 |
| Max. Negotiated Rate |
$8,699.74 |
| Rate for Payer: Cash Price |
$5,494.57
|
| Rate for Payer: Cigna Commercial |
$7,783.98
|
| Rate for Payer: First Health Commercial |
$8,241.86
|
| Rate for Payer: First Health Workers Compensation |
$3,535.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,241.86
|
| Rate for Payer: GEHA Commercial |
$6,410.33
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,241.86
|
| Rate for Payer: Multiplan All |
$8,333.43
|
| Rate for Payer: OMNI Networks Commercial |
$6,410.33
|
| Rate for Payer: One Health Plan PPO/POS |
$8,241.86
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,699.74
|
| Rate for Payer: Three Rivers Provider Network All |
$6,868.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,516.59
|
| Rate for Payer: Zelis Auto |
$3,663.05
|
| Rate for Payer: Zelis Worker's Compensation |
$2,500.03
|
|
|
THERASKIN 2.5CM X 1CM
|
Facility
|
OP
|
$3,486.54
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$3,312.21 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,091.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$2,091.92
|
| Rate for Payer: Cash Price |
$2,091.92
|
| Rate for Payer: Cigna Commercial |
$2,963.56
|
| Rate for Payer: First Health Commercial |
$3,137.89
|
| Rate for Payer: First Health Workers Compensation |
$1,346.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,137.89
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,137.89
|
| Rate for Payer: Humana ChoiceCare |
$906.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$3,172.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,091.92
|
| Rate for Payer: OMNI Networks Commercial |
$2,440.58
|
| Rate for Payer: One Health Plan PPO/POS |
$3,137.89
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,312.21
|
| Rate for Payer: Three Rivers Provider Network All |
$2,614.91
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,068.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,242.48
|
| Rate for Payer: Zelis Auto |
$1,394.62
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,743.27
|
| Rate for Payer: Zelis Worker's Compensation |
$951.83
|
|
|
THERASKIN 2.5CM X 1CM
|
Facility
|
IP
|
$3,486.54
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$951.83 |
| Max. Negotiated Rate |
$3,312.21 |
| Rate for Payer: Cash Price |
$2,091.92
|
| Rate for Payer: Cigna Commercial |
$2,963.56
|
| Rate for Payer: First Health Commercial |
$3,137.89
|
| Rate for Payer: First Health Workers Compensation |
$1,346.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,137.89
|
| Rate for Payer: GEHA Commercial |
$2,440.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,137.89
|
| Rate for Payer: Multiplan All |
$3,172.75
|
| Rate for Payer: OMNI Networks Commercial |
$2,440.58
|
| Rate for Payer: One Health Plan PPO/POS |
$3,137.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,312.21
|
| Rate for Payer: Three Rivers Provider Network All |
$2,614.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,242.48
|
| Rate for Payer: Zelis Auto |
$1,394.62
|
| Rate for Payer: Zelis Worker's Compensation |
$951.83
|
|
|
THERASKIN 4CM X 6.5CM
|
Facility
|
OP
|
$4,035.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$3,833.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,421.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cigna Commercial |
$3,429.75
|
| Rate for Payer: First Health Commercial |
$3,631.50
|
| Rate for Payer: First Health Workers Compensation |
$1,557.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,631.50
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,631.50
|
| Rate for Payer: Humana ChoiceCare |
$1,049.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$3,671.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,421.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,824.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,631.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,833.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,026.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,550.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,752.55
|
| Rate for Payer: Zelis Auto |
$1,614.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,017.50
|
| Rate for Payer: Zelis Worker's Compensation |
$1,101.56
|
|
|
THERASKIN 4CM X 6.5CM
|
Facility
|
IP
|
$4,035.00
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,101.56 |
| Max. Negotiated Rate |
$3,833.25 |
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cigna Commercial |
$3,429.75
|
| Rate for Payer: First Health Commercial |
$3,631.50
|
| Rate for Payer: First Health Workers Compensation |
$1,557.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,631.50
|
| Rate for Payer: GEHA Commercial |
$2,824.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,631.50
|
| Rate for Payer: Multiplan All |
$3,671.85
|
| Rate for Payer: OMNI Networks Commercial |
$2,824.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,631.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,833.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,026.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,752.55
|
| Rate for Payer: Zelis Auto |
$1,614.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,101.56
|
|
|
THERASKIN 5.1CM X 7.6CM
|
Facility
|
OP
|
$5,521.72
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$5,245.63 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,313.03
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$175.46
|
| Rate for Payer: Cash Price |
$3,313.03
|
| Rate for Payer: Cash Price |
$3,313.03
|
| Rate for Payer: Cigna Commercial |
$4,693.46
|
| Rate for Payer: First Health Commercial |
$4,969.55
|
| Rate for Payer: First Health Workers Compensation |
$2,131.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,969.55
|
| Rate for Payer: GEHA Commercial |
$152.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,969.55
|
| Rate for Payer: Humana ChoiceCare |
$1,435.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$179.04
|
| Rate for Payer: Multiplan All |
$5,024.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,313.03
|
| Rate for Payer: OMNI Networks Commercial |
$3,865.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,969.55
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$206.72
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$179.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,245.63
|
| Rate for Payer: Three Rivers Provider Network All |
$4,141.29
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,859.11
|
| Rate for Payer: United Healthcare Managed Medicaid |
$179.04
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,135.20
|
| Rate for Payer: Zelis Auto |
$2,208.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,760.86
|
| Rate for Payer: Zelis Worker's Compensation |
$1,507.43
|
|
|
THERASKIN 5.1CM X 7.6CM
|
Facility
|
IP
|
$5,521.72
|
|
|
Service Code
|
CPT Q4133
|
| Hospital Charge Code |
7006781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,507.43 |
| Max. Negotiated Rate |
$5,245.63 |
| Rate for Payer: Cash Price |
$3,313.03
|
| Rate for Payer: Cigna Commercial |
$4,693.46
|
| Rate for Payer: First Health Commercial |
$4,969.55
|
| Rate for Payer: First Health Workers Compensation |
$2,131.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,969.55
|
| Rate for Payer: GEHA Commercial |
$3,865.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,969.55
|
| Rate for Payer: Multiplan All |
$5,024.77
|
| Rate for Payer: OMNI Networks Commercial |
$3,865.20
|
| Rate for Payer: One Health Plan PPO/POS |
$4,969.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,245.63
|
| Rate for Payer: Three Rivers Provider Network All |
$4,141.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,135.20
|
| Rate for Payer: Zelis Auto |
$2,208.69
|
| Rate for Payer: Zelis Worker's Compensation |
$1,507.43
|
|
|
Theraskin, per square cm
|
Facility
|
IP
|
$485.53
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
194121
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.55 |
| Max. Negotiated Rate |
$461.25 |
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cigna Commercial |
$412.70
|
| Rate for Payer: First Health Commercial |
$436.98
|
| Rate for Payer: First Health Workers Compensation |
$187.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.98
|
| Rate for Payer: GEHA Commercial |
$339.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.98
|
| Rate for Payer: Multiplan All |
$441.83
|
| Rate for Payer: OMNI Networks Commercial |
$339.87
|
| Rate for Payer: One Health Plan PPO/POS |
$436.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$461.25
|
| Rate for Payer: Three Rivers Provider Network All |
$364.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.54
|
| Rate for Payer: Zelis Auto |
$194.21
|
| Rate for Payer: Zelis Worker's Compensation |
$132.55
|
|
|
Theraskin, per square cm
|
Facility
|
OP
|
$485.53
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
9604121
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.23 |
| Max. Negotiated Rate |
$461.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.23
|
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cigna Commercial |
$412.70
|
| Rate for Payer: First Health Commercial |
$436.98
|
| Rate for Payer: First Health Workers Compensation |
$187.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.98
|
| Rate for Payer: GEHA Commercial |
$58.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.98
|
| Rate for Payer: Humana ChoiceCare |
$126.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.29
|
| Rate for Payer: Multiplan All |
$441.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.32
|
| Rate for Payer: OMNI Networks Commercial |
$339.87
|
| Rate for Payer: One Health Plan PPO/POS |
$436.98
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$461.25
|
| Rate for Payer: Three Rivers Provider Network All |
$364.15
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$427.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.54
|
| Rate for Payer: Zelis Auto |
$194.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.76
|
| Rate for Payer: Zelis Worker's Compensation |
$132.55
|
|
|
Theraskin, per square cm
|
Facility
|
IP
|
$485.53
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
9604121
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.55 |
| Max. Negotiated Rate |
$461.25 |
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cigna Commercial |
$412.70
|
| Rate for Payer: First Health Commercial |
$436.98
|
| Rate for Payer: First Health Workers Compensation |
$187.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.98
|
| Rate for Payer: GEHA Commercial |
$339.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.98
|
| Rate for Payer: Multiplan All |
$441.83
|
| Rate for Payer: OMNI Networks Commercial |
$339.87
|
| Rate for Payer: One Health Plan PPO/POS |
$436.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$461.25
|
| Rate for Payer: Three Rivers Provider Network All |
$364.15
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.54
|
| Rate for Payer: Zelis Auto |
$194.21
|
| Rate for Payer: Zelis Worker's Compensation |
$132.55
|
|
|
Theraskin, per square cm
|
Facility
|
OP
|
$485.53
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
194121
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.23 |
| Max. Negotiated Rate |
$461.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.32
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.23
|
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cash Price |
$291.32
|
| Rate for Payer: Cigna Commercial |
$412.70
|
| Rate for Payer: First Health Commercial |
$436.98
|
| Rate for Payer: First Health Workers Compensation |
$187.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.98
|
| Rate for Payer: GEHA Commercial |
$58.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.98
|
| Rate for Payer: Humana ChoiceCare |
$126.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.29
|
| Rate for Payer: Multiplan All |
$441.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.32
|
| Rate for Payer: OMNI Networks Commercial |
$339.87
|
| Rate for Payer: One Health Plan PPO/POS |
$436.98
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$461.25
|
| Rate for Payer: Three Rivers Provider Network All |
$364.15
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$427.27
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.54
|
| Rate for Payer: Zelis Auto |
$194.21
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.76
|
| Rate for Payer: Zelis Worker's Compensation |
$132.55
|
|
|
Theraskin, per square cm - SAMPLE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
194122
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$65.92 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.23
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: First Health Workers Compensation |
$0.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$0.01
|
| Rate for Payer: GEHA Commercial |
$58.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.29
|
| Rate for Payer: Multiplan All |
$0.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$0.01
|
| Rate for Payer: OMNI Networks Commercial |
$0.01
|
| Rate for Payer: One Health Plan PPO/POS |
$0.01
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$0.01
|
| Rate for Payer: Three Rivers Provider Network All |
$0.01
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$0.01
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$0.01
|
| Rate for Payer: Zelis Auto |
$0.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$0.01
|
| Rate for Payer: Zelis Worker's Compensation |
$0.00
|
|
