|
TIMOLOL 0.5% OPTH SOLN
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 60758080105
|
| Hospital Charge Code |
3300894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$89.25
|
| Rate for Payer: First Health Commercial |
$94.50
|
| Rate for Payer: First Health Workers Compensation |
$40.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$94.50
|
| Rate for Payer: GEHA Commercial |
$73.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$94.50
|
| Rate for Payer: Multiplan All |
$95.55
|
| Rate for Payer: OMNI Networks Commercial |
$73.50
|
| Rate for Payer: One Health Plan PPO/POS |
$94.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$99.75
|
| Rate for Payer: Three Rivers Provider Network All |
$78.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$97.65
|
| Rate for Payer: Zelis Auto |
$42.00
|
| Rate for Payer: Zelis Worker's Compensation |
$28.66
|
|
|
TIMOLOL 0.5% OPTH SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 60758080105
|
| Hospital Charge Code |
3300894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$89.25
|
| Rate for Payer: First Health Commercial |
$94.50
|
| Rate for Payer: First Health Workers Compensation |
$40.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$94.50
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$94.50
|
| Rate for Payer: Humana ChoiceCare |
$27.30
|
| Rate for Payer: Multiplan All |
$95.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.00
|
| Rate for Payer: OMNI Networks Commercial |
$73.50
|
| Rate for Payer: One Health Plan PPO/POS |
$94.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$99.75
|
| Rate for Payer: Three Rivers Provider Network All |
$78.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$92.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$97.65
|
| Rate for Payer: Zelis Auto |
$42.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.50
|
| Rate for Payer: Zelis Worker's Compensation |
$28.66
|
|
|
timothy grass IgE REF602506
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299156
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: GEHA Medicare |
$5.22
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.59
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$5.22
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.87
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$8.76
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.59
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$5.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$10.44
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$47.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$5.22
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Medicare |
$4.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6.26
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
timothy grass IgE REF602506
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
2299156
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$47.60
|
| Rate for Payer: First Health Commercial |
$50.40
|
| Rate for Payer: First Health Workers Compensation |
$11.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$39.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: OMNI Networks Commercial |
$39.20
|
| Rate for Payer: One Health Plan PPO/POS |
$50.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$53.20
|
| Rate for Payer: Three Rivers Provider Network All |
$42.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Worker's Compensation |
$7.93
|
|
|
TISSUE CULTURE NEOPL DIS BONE MAR BLD CE
|
Facility
|
IP
|
$863.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
2200408
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$136.32 |
| Max. Negotiated Rate |
$819.85 |
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$733.55
|
| Rate for Payer: First Health Commercial |
$776.70
|
| Rate for Payer: First Health Workers Compensation |
$192.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$776.70
|
| Rate for Payer: GEHA Commercial |
$604.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$776.70
|
| Rate for Payer: Multiplan All |
$785.33
|
| Rate for Payer: OMNI Networks Commercial |
$604.10
|
| Rate for Payer: One Health Plan PPO/POS |
$776.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$819.85
|
| Rate for Payer: Three Rivers Provider Network All |
$647.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$802.59
|
| Rate for Payer: Zelis Auto |
$345.20
|
| Rate for Payer: Zelis Worker's Compensation |
$136.32
|
|
|
TISSUE CULTURE NEOPL DIS BONE MAR BLD CE
|
Facility
|
OP
|
$863.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
2200408
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.19 |
| Max. Negotiated Rate |
$819.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$258.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$517.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$258.74
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$204.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$143.75
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cash Price |
$517.80
|
| Rate for Payer: Cigna Commercial |
$733.55
|
| Rate for Payer: First Health Commercial |
$776.70
|
| Rate for Payer: First Health Workers Compensation |
$192.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$776.70
|
| Rate for Payer: GEHA Commercial |
$690.40
|
| Rate for Payer: GEHA Medicare |
$143.75
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$776.70
|
| Rate for Payer: Humana ChoiceCare |
$158.12
|
| Rate for Payer: Humana Medicare Advantage |
$143.75
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$241.50
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$209.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$143.75
|
| Rate for Payer: Multiplan All |
$785.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$244.38
|
| Rate for Payer: OMNI Networks Commercial |
$604.10
|
| Rate for Payer: One Health Plan PPO/POS |
$776.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$241.49
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$209.14
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$143.75
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$819.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$287.50
|
| Rate for Payer: Three Rivers Provider Network All |
$647.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$140.88
|
| Rate for Payer: United Healthcare Commercial |
$733.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$209.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$802.59
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$143.75
|
| Rate for Payer: Zelis Auto |
$345.20
|
| Rate for Payer: Zelis Medicare |
$122.19
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$172.50
|
| Rate for Payer: Zelis Worker's Compensation |
$136.32
|
|
|
TISSUE SEALER CURVED
|
Facility
|
OP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$601.58 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,925.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Humana ChoiceCare |
$625.65
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,443.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,117.57
|
| Rate for Payer: United Healthcare Managed Medicaid |
$601.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,203.16
|
|
|
TISSUE SEALER CURVED
|
Facility
|
IP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$962.53 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,925.06
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,684.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
|
|
TISSUE SEALER LARGE ENSEAL
|
Facility
|
IP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$962.53 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,925.06
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,684.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
|
|
TISSUE SEALER LARGE ENSEAL
|
Facility
|
OP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$601.58 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,925.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Humana ChoiceCare |
$625.65
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,443.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,117.57
|
| Rate for Payer: United Healthcare Managed Medicaid |
$601.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,203.16
|
|
|
TISSUE SEALER STRAIGHT
|
Facility
|
IP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$962.53 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,925.06
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,684.43
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
|
|
TISSUE SEALER STRAIGHT
|
Facility
|
OP
|
$2,406.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$601.58 |
| Max. Negotiated Rate |
$2,286.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cash Price |
$1,443.80
|
| Rate for Payer: Cigna Commercial |
$2,045.38
|
| Rate for Payer: First Health Commercial |
$2,165.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.70
|
| Rate for Payer: GEHA Commercial |
$1,925.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.70
|
| Rate for Payer: Humana ChoiceCare |
$625.65
|
| Rate for Payer: Multiplan All |
$2,189.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,443.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.43
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,286.01
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,117.57
|
| Rate for Payer: United Healthcare Managed Medicaid |
$601.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.89
|
| Rate for Payer: Zelis Auto |
$962.53
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,203.16
|
|
|
tissue transglutaminase, IgA REF164640
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2299087
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$20.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$151.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
tissue transglutaminase, IgA REF164640
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2299087
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.53
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$20.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: GEHA Medicare |
$11.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$12.68
|
| Rate for Payer: Humana Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.53
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.60
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.06
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.30
|
| Rate for Payer: United Healthcare Commercial |
$184.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.53
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Medicare |
$9.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.84
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
tissue transglutaminase IgG REF164988
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2200458
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$20.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$20.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$11.53
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$20.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: GEHA Medicare |
$11.53
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Humana ChoiceCare |
$12.68
|
| Rate for Payer: Humana Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$19.37
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$16.78
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$11.53
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$19.60
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$19.38
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$16.78
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$11.53
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$23.06
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11.30
|
| Rate for Payer: United Healthcare Commercial |
$184.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$11.53
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Medicare |
$9.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.84
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
tissue transglutaminase IgG REF164988
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2200458
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$184.45
|
| Rate for Payer: First Health Commercial |
$195.30
|
| Rate for Payer: First Health Workers Compensation |
$20.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$195.30
|
| Rate for Payer: GEHA Commercial |
$151.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$195.30
|
| Rate for Payer: Multiplan All |
$197.47
|
| Rate for Payer: OMNI Networks Commercial |
$151.90
|
| Rate for Payer: One Health Plan PPO/POS |
$195.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$206.15
|
| Rate for Payer: Three Rivers Provider Network All |
$162.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$201.81
|
| Rate for Payer: Zelis Auto |
$86.80
|
| Rate for Payer: Zelis Worker's Compensation |
$14.20
|
|
|
TIS TRNFR ADDL 30 SQ CM/<
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 14302
|
| Hospital Charge Code |
6114302
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$150.02 |
| Max. Negotiated Rate |
$2,419.71 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$346.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$490.45
|
| Rate for Payer: First Health Commercial |
$519.30
|
| Rate for Payer: First Health Workers Compensation |
$222.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$519.30
|
| Rate for Payer: GEHA Commercial |
$461.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$519.30
|
| Rate for Payer: Humana ChoiceCare |
$150.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Multiplan All |
$525.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$346.20
|
| Rate for Payer: OMNI Networks Commercial |
$403.90
|
| Rate for Payer: One Health Plan PPO/POS |
$519.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$548.15
|
| Rate for Payer: Three Rivers Provider Network All |
$432.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$507.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$536.61
|
| Rate for Payer: Zelis Auto |
$230.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$288.50
|
| Rate for Payer: Zelis Worker's Compensation |
$157.52
|
|
|
TIS TRNFR ADDL 30 SQ CM/<
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
CPT 14302
|
| Hospital Charge Code |
6114302
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$157.52 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$490.45
|
| Rate for Payer: First Health Commercial |
$519.30
|
| Rate for Payer: First Health Workers Compensation |
$222.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$519.30
|
| Rate for Payer: GEHA Commercial |
$403.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$519.30
|
| Rate for Payer: Multiplan All |
$525.07
|
| Rate for Payer: OMNI Networks Commercial |
$403.90
|
| Rate for Payer: One Health Plan PPO/POS |
$519.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$548.15
|
| Rate for Payer: Three Rivers Provider Network All |
$432.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$536.61
|
| Rate for Payer: Zelis Auto |
$230.80
|
| Rate for Payer: Zelis Worker's Compensation |
$157.52
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM
|
Facility
|
OP
|
$1,809.00
|
|
|
Service Code
|
CPT 14301
|
| Hospital Charge Code |
6114301
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$493.86 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,085.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$2,419.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,916.89
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,476.24
|
| Rate for Payer: Cash Price |
$1,085.40
|
| Rate for Payer: Cash Price |
$1,085.40
|
| Rate for Payer: Cigna Commercial |
$1,537.65
|
| Rate for Payer: First Health Commercial |
$1,628.10
|
| Rate for Payer: First Health Workers Compensation |
$698.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,628.10
|
| Rate for Payer: GEHA Commercial |
$1,447.20
|
| Rate for Payer: GEHA Medicare |
$3,476.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,628.10
|
| Rate for Payer: Humana ChoiceCare |
$3,823.86
|
| Rate for Payer: Humana Medicare Advantage |
$3,476.24
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,840.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,955.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,476.24
|
| Rate for Payer: Multiplan All |
$1,646.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,909.61
|
| Rate for Payer: OMNI Networks Commercial |
$1,266.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,628.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,258.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,955.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,476.24
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,718.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,952.48
|
| Rate for Payer: Three Rivers Provider Network All |
$1,356.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,406.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,955.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,476.24
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,682.37
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,476.24
|
| Rate for Payer: Zelis Auto |
$723.60
|
| Rate for Payer: Zelis Medicare |
$2,954.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,171.49
|
| Rate for Payer: Zelis Worker's Compensation |
$493.86
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM
|
Facility
|
IP
|
$1,809.00
|
|
|
Service Code
|
CPT 14301
|
| Hospital Charge Code |
6114301
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$493.86 |
| Max. Negotiated Rate |
$1,718.55 |
| Rate for Payer: Cash Price |
$1,085.40
|
| Rate for Payer: Cigna Commercial |
$1,537.65
|
| Rate for Payer: First Health Commercial |
$1,628.10
|
| Rate for Payer: First Health Workers Compensation |
$698.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,628.10
|
| Rate for Payer: GEHA Commercial |
$1,266.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,628.10
|
| Rate for Payer: Multiplan All |
$1,646.19
|
| Rate for Payer: OMNI Networks Commercial |
$1,266.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,628.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,718.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,356.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,682.37
|
| Rate for Payer: Zelis Auto |
$723.60
|
| Rate for Payer: Zelis Worker's Compensation |
$493.86
|
|
|
TIS TRNFR E/N/E/L10.1-30SQCM
|
Facility
|
IP
|
$1,699.00
|
|
|
Service Code
|
CPT 14061
|
| Hospital Charge Code |
6114061
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$463.83 |
| Max. Negotiated Rate |
$1,614.05 |
| Rate for Payer: Cash Price |
$1,019.40
|
| Rate for Payer: Cigna Commercial |
$1,444.15
|
| Rate for Payer: First Health Commercial |
$1,529.10
|
| Rate for Payer: First Health Workers Compensation |
$655.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,529.10
|
| Rate for Payer: GEHA Commercial |
$1,189.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,529.10
|
| Rate for Payer: Multiplan All |
$1,546.09
|
| Rate for Payer: OMNI Networks Commercial |
$1,189.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,529.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,614.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,274.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,580.07
|
| Rate for Payer: Zelis Auto |
$679.60
|
| Rate for Payer: Zelis Worker's Compensation |
$463.83
|
|
|
TIS TRNFR E/N/E/L10.1-30SQCM
|
Facility
|
OP
|
$1,699.00
|
|
|
Service Code
|
CPT 14061
|
| Hospital Charge Code |
6114061
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$463.83 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,019.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$1,019.40
|
| Rate for Payer: Cash Price |
$1,019.40
|
| Rate for Payer: Cigna Commercial |
$1,444.15
|
| Rate for Payer: First Health Commercial |
$1,529.10
|
| Rate for Payer: First Health Workers Compensation |
$655.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,529.10
|
| Rate for Payer: GEHA Commercial |
$1,359.20
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,529.10
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,546.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$1,189.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,529.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,614.05
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,274.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,580.07
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$679.60
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$463.83
|
|
|
TIS TRNFR E/N/E/L 10 SQ CM/<
|
Facility
|
OP
|
$1,372.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
6114060
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$3,473.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$823.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,623.22
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,285.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$1,736.93
|
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cigna Commercial |
$1,166.20
|
| Rate for Payer: First Health Commercial |
$1,234.80
|
| Rate for Payer: First Health Workers Compensation |
$529.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,234.80
|
| Rate for Payer: GEHA Commercial |
$1,097.60
|
| Rate for Payer: GEHA Medicare |
$1,736.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,234.80
|
| Rate for Payer: Humana ChoiceCare |
$1,910.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,736.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$2,918.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,312.11
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$1,736.93
|
| Rate for Payer: Multiplan All |
$1,248.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,952.78
|
| Rate for Payer: OMNI Networks Commercial |
$960.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,234.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,515.01
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,312.11
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$1,736.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,303.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$3,473.86
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,702.19
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,312.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,736.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,275.96
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$1,736.93
|
| Rate for Payer: Zelis Auto |
$548.80
|
| Rate for Payer: Zelis Medicare |
$1,476.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,084.32
|
| Rate for Payer: Zelis Worker's Compensation |
$374.56
|
|
|
TIS TRNFR E/N/E/L 10 SQ CM/<
|
Facility
|
IP
|
$1,372.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
6114060
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$1,303.40 |
| Rate for Payer: Cash Price |
$823.20
|
| Rate for Payer: Cigna Commercial |
$1,166.20
|
| Rate for Payer: First Health Commercial |
$1,234.80
|
| Rate for Payer: First Health Workers Compensation |
$529.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,234.80
|
| Rate for Payer: GEHA Commercial |
$960.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,234.80
|
| Rate for Payer: Multiplan All |
$1,248.52
|
| Rate for Payer: OMNI Networks Commercial |
$960.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,234.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,303.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,029.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,275.96
|
| Rate for Payer: Zelis Auto |
$548.80
|
| Rate for Payer: Zelis Worker's Compensation |
$374.56
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$1,588.00
|
|
|
Service Code
|
CPT 14041
|
| Hospital Charge Code |
6114041
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$433.52 |
| Max. Negotiated Rate |
$1,508.60 |
| Rate for Payer: Cash Price |
$952.80
|
| Rate for Payer: Cigna Commercial |
$1,349.80
|
| Rate for Payer: First Health Commercial |
$1,429.20
|
| Rate for Payer: First Health Workers Compensation |
$613.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,429.20
|
| Rate for Payer: GEHA Commercial |
$1,111.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,429.20
|
| Rate for Payer: Multiplan All |
$1,445.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,111.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,429.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,508.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,191.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,476.84
|
| Rate for Payer: Zelis Auto |
$635.20
|
| Rate for Payer: Zelis Worker's Compensation |
$433.52
|
|
