|
TROPICAMIDE OPTH SOLN 1%
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
NDC 24208058559
|
| Hospital Charge Code |
3300928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$87.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: First Health Commercial |
$82.80
|
| Rate for Payer: First Health Workers Compensation |
$35.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$82.80
|
| Rate for Payer: GEHA Commercial |
$73.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$82.80
|
| Rate for Payer: Humana ChoiceCare |
$23.92
|
| Rate for Payer: Multiplan All |
$83.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$55.20
|
| Rate for Payer: OMNI Networks Commercial |
$64.40
|
| Rate for Payer: One Health Plan PPO/POS |
$82.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$87.40
|
| Rate for Payer: Three Rivers Provider Network All |
$69.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$85.56
|
| Rate for Payer: Zelis Auto |
$36.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$46.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.12
|
|
|
TROPONIN I (Vitros)
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 84484
|
| Hospital Charge Code |
2232188
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$137.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$22.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.78
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$12.47
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$16.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$183.20
|
| Rate for Payer: GEHA Medicare |
$12.47
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Humana ChoiceCare |
$13.72
|
| Rate for Payer: Humana Medicare Advantage |
$12.47
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$20.95
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$18.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$12.47
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$21.20
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$18.14
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$12.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$24.94
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.22
|
| Rate for Payer: United Healthcare Commercial |
$194.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$18.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$12.47
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Medicare |
$10.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14.96
|
| Rate for Payer: Zelis Worker's Compensation |
$11.81
|
|
|
TROPONIN I (Vitros)
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 84484
|
| Hospital Charge Code |
2232188
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$16.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$160.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Worker's Compensation |
$11.81
|
|
|
TRT CONCURRENT INFUS ONCE PER ENCOUNTER
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
1996368
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$86.00 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$206.40
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cigna Commercial |
$292.40
|
| Rate for Payer: First Health Commercial |
$309.60
|
| Rate for Payer: First Health Workers Compensation |
$132.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$309.60
|
| Rate for Payer: GEHA Commercial |
$275.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$309.60
|
| Rate for Payer: Humana ChoiceCare |
$89.44
|
| Rate for Payer: Multiplan All |
$313.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$206.40
|
| Rate for Payer: OMNI Networks Commercial |
$240.80
|
| Rate for Payer: One Health Plan PPO/POS |
$309.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$326.80
|
| Rate for Payer: Three Rivers Provider Network All |
$258.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$302.72
|
| Rate for Payer: United Healthcare Commercial |
$292.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$319.92
|
| Rate for Payer: Zelis Auto |
$137.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$172.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.91
|
|
|
TRT CONCURRENT INFUS ONCE PER ENCOUNTER
|
Facility
|
IP
|
$582.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
7896368
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$158.89 |
| Max. Negotiated Rate |
$552.90 |
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$494.70
|
| Rate for Payer: First Health Commercial |
$523.80
|
| Rate for Payer: First Health Workers Compensation |
$224.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$523.80
|
| Rate for Payer: GEHA Commercial |
$407.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$523.80
|
| Rate for Payer: Multiplan All |
$529.62
|
| Rate for Payer: OMNI Networks Commercial |
$407.40
|
| Rate for Payer: One Health Plan PPO/POS |
$523.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$552.90
|
| Rate for Payer: Three Rivers Provider Network All |
$436.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$541.26
|
| Rate for Payer: Zelis Auto |
$232.80
|
| Rate for Payer: Zelis Worker's Compensation |
$158.89
|
|
|
TRT CONCURRENT INFUS ONCE PER ENCOUNTER
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
1996368
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$93.91 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cigna Commercial |
$292.40
|
| Rate for Payer: First Health Commercial |
$309.60
|
| Rate for Payer: First Health Workers Compensation |
$132.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$309.60
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$309.60
|
| Rate for Payer: Multiplan All |
$313.04
|
| Rate for Payer: OMNI Networks Commercial |
$240.80
|
| Rate for Payer: One Health Plan PPO/POS |
$309.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$326.80
|
| Rate for Payer: Three Rivers Provider Network All |
$258.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$319.92
|
| Rate for Payer: Zelis Auto |
$137.60
|
| Rate for Payer: Zelis Worker's Compensation |
$93.91
|
|
|
TRT CONCURRENT INFUS ONCE PER ENCOUNTER
|
Facility
|
OP
|
$582.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
7896368
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$145.50 |
| Max. Negotiated Rate |
$552.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$494.70
|
| Rate for Payer: First Health Commercial |
$523.80
|
| Rate for Payer: First Health Workers Compensation |
$224.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$523.80
|
| Rate for Payer: GEHA Commercial |
$465.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$523.80
|
| Rate for Payer: Humana ChoiceCare |
$151.32
|
| Rate for Payer: Multiplan All |
$529.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$349.20
|
| Rate for Payer: OMNI Networks Commercial |
$407.40
|
| Rate for Payer: One Health Plan PPO/POS |
$523.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$552.90
|
| Rate for Payer: Three Rivers Provider Network All |
$436.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$512.16
|
| Rate for Payer: United Healthcare Commercial |
$494.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$145.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$541.26
|
| Rate for Payer: Zelis Auto |
$232.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$291.00
|
| Rate for Payer: Zelis Worker's Compensation |
$158.89
|
|
|
TRT HYDRATION EACH ADDITIONAL HOUR
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
1996361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$83.27 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
TRT HYDRATION EACH ADDITIONAL HOUR
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
7896361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$229.90 |
| 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 |
$145.20
|
| 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 |
$43.81
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$205.70
|
| Rate for Payer: First Health Commercial |
$217.80
|
| Rate for Payer: First Health Workers Compensation |
$93.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$217.80
|
| Rate for Payer: GEHA Commercial |
$193.60
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$217.80
|
| 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 |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$220.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$169.40
|
| Rate for Payer: One Health Plan PPO/POS |
$217.80
|
| 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 |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$229.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$181.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$205.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.06
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$96.80
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$66.07
|
|
|
TRT HYDRATION EACH ADDITIONAL HOUR
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
7896361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$66.07 |
| Max. Negotiated Rate |
$229.90 |
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$205.70
|
| Rate for Payer: First Health Commercial |
$217.80
|
| Rate for Payer: First Health Workers Compensation |
$93.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$217.80
|
| Rate for Payer: GEHA Commercial |
$169.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$217.80
|
| Rate for Payer: Multiplan All |
$220.22
|
| Rate for Payer: OMNI Networks Commercial |
$169.40
|
| Rate for Payer: One Health Plan PPO/POS |
$217.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$229.90
|
| Rate for Payer: Three Rivers Provider Network All |
$181.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$225.06
|
| Rate for Payer: Zelis Auto |
$96.80
|
| Rate for Payer: Zelis Worker's Compensation |
$66.07
|
|
|
TRT HYDRATION EACH ADDITIONAL HOUR
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
1996361
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$289.75 |
| 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 |
$183.00
|
| 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 |
$43.81
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| 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 |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| 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 |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$259.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
TRT INFUSION EACH ADDL HOUR
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
1996366
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$86.54 |
| Max. Negotiated Rate |
$301.15 |
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$269.45
|
| Rate for Payer: First Health Commercial |
$285.30
|
| Rate for Payer: First Health Workers Compensation |
$122.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$285.30
|
| Rate for Payer: GEHA Commercial |
$221.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$285.30
|
| Rate for Payer: Multiplan All |
$288.47
|
| Rate for Payer: OMNI Networks Commercial |
$221.90
|
| Rate for Payer: One Health Plan PPO/POS |
$285.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$301.15
|
| Rate for Payer: Three Rivers Provider Network All |
$237.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$294.81
|
| Rate for Payer: Zelis Auto |
$126.80
|
| Rate for Payer: Zelis Worker's Compensation |
$86.54
|
|
|
TRT INFUSION EACH ADDL HOUR
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
1996366
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$301.15 |
| 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 |
$190.20
|
| 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 |
$43.81
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$269.45
|
| Rate for Payer: First Health Commercial |
$285.30
|
| Rate for Payer: First Health Workers Compensation |
$122.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$285.30
|
| Rate for Payer: GEHA Commercial |
$253.60
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$285.30
|
| 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 |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$288.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$221.90
|
| Rate for Payer: One Health Plan PPO/POS |
$285.30
|
| 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 |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$301.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$237.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$269.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$294.81
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$126.80
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$86.54
|
|
|
TRT INFUSION EACH ADDL HOUR
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
7896366
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$210.80
|
| Rate for Payer: First Health Commercial |
$223.20
|
| Rate for Payer: First Health Workers Compensation |
$95.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$223.20
|
| Rate for Payer: GEHA Commercial |
$173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$223.20
|
| Rate for Payer: Multiplan All |
$225.68
|
| Rate for Payer: OMNI Networks Commercial |
$173.60
|
| Rate for Payer: One Health Plan PPO/POS |
$223.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$235.60
|
| Rate for Payer: Three Rivers Provider Network All |
$186.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$230.64
|
| Rate for Payer: Zelis Auto |
$99.20
|
| Rate for Payer: Zelis Worker's Compensation |
$67.70
|
|
|
TRT INFUSION EACH ADDL HOUR
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
7896366
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$235.60 |
| 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 |
$148.80
|
| 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 |
$43.81
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$210.80
|
| Rate for Payer: First Health Commercial |
$223.20
|
| Rate for Payer: First Health Workers Compensation |
$95.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$223.20
|
| Rate for Payer: GEHA Commercial |
$198.40
|
| Rate for Payer: GEHA Medicare |
$43.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$223.20
|
| 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 |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$43.81
|
| Rate for Payer: Multiplan All |
$225.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$74.48
|
| Rate for Payer: OMNI Networks Commercial |
$173.60
|
| Rate for Payer: One Health Plan PPO/POS |
$223.20
|
| 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 |
$43.81
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$235.60
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$87.62
|
| Rate for Payer: Three Rivers Provider Network All |
$186.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42.93
|
| Rate for Payer: United Healthcare Commercial |
$210.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$230.64
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$43.81
|
| Rate for Payer: Zelis Auto |
$99.20
|
| Rate for Payer: Zelis Medicare |
$37.24
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$52.57
|
| Rate for Payer: Zelis Worker's Compensation |
$67.70
|
|
|
TRT INFUSION INITIAL HOUR
|
Facility
|
IP
|
$683.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
7896365
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$186.46 |
| Max. Negotiated Rate |
$648.85 |
| Rate for Payer: Cash Price |
$409.80
|
| Rate for Payer: Cigna Commercial |
$580.55
|
| Rate for Payer: First Health Commercial |
$614.70
|
| Rate for Payer: First Health Workers Compensation |
$263.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$614.70
|
| Rate for Payer: GEHA Commercial |
$478.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$614.70
|
| Rate for Payer: Multiplan All |
$621.53
|
| Rate for Payer: OMNI Networks Commercial |
$478.10
|
| Rate for Payer: One Health Plan PPO/POS |
$614.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$648.85
|
| Rate for Payer: Three Rivers Provider Network All |
$512.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$635.19
|
| Rate for Payer: Zelis Auto |
$273.20
|
| Rate for Payer: Zelis Worker's Compensation |
$186.46
|
|
|
TRT INFUSION INITIAL HOUR
|
Facility
|
OP
|
$683.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
7896365
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$150.65 |
| Max. Negotiated Rate |
$648.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$409.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$150.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$200.06
|
| Rate for Payer: Cash Price |
$409.80
|
| Rate for Payer: Cash Price |
$409.80
|
| Rate for Payer: Cigna Commercial |
$580.55
|
| Rate for Payer: First Health Commercial |
$614.70
|
| Rate for Payer: First Health Workers Compensation |
$263.71
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$614.70
|
| Rate for Payer: GEHA Commercial |
$546.40
|
| Rate for Payer: GEHA Medicare |
$200.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$614.70
|
| Rate for Payer: Humana ChoiceCare |
$220.07
|
| Rate for Payer: Humana Medicare Advantage |
$200.06
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$336.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$153.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$200.06
|
| Rate for Payer: Multiplan All |
$621.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.10
|
| Rate for Payer: OMNI Networks Commercial |
$478.10
|
| Rate for Payer: One Health Plan PPO/POS |
$614.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$177.49
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$153.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$200.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$648.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$400.12
|
| Rate for Payer: Three Rivers Provider Network All |
$512.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$196.06
|
| Rate for Payer: United Healthcare Commercial |
$580.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$153.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.06
|
| Rate for Payer: United Payors & United Providers UP&UP |
$635.19
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$200.06
|
| Rate for Payer: Zelis Auto |
$273.20
|
| Rate for Payer: Zelis Medicare |
$170.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$240.07
|
| Rate for Payer: Zelis Worker's Compensation |
$186.46
|
|
|
TRT INFUSION INITIAL HOUR
|
Facility
|
OP
|
$812.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
1996365
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$150.65 |
| Max. Negotiated Rate |
$771.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$487.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$150.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$200.06
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$690.20
|
| Rate for Payer: First Health Commercial |
$730.80
|
| Rate for Payer: First Health Workers Compensation |
$313.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$730.80
|
| Rate for Payer: GEHA Commercial |
$649.60
|
| Rate for Payer: GEHA Medicare |
$200.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$730.80
|
| Rate for Payer: Humana ChoiceCare |
$220.07
|
| Rate for Payer: Humana Medicare Advantage |
$200.06
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$336.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$153.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$200.06
|
| Rate for Payer: Multiplan All |
$738.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.10
|
| Rate for Payer: OMNI Networks Commercial |
$568.40
|
| Rate for Payer: One Health Plan PPO/POS |
$730.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$177.49
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$153.72
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$200.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$771.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$400.12
|
| Rate for Payer: Three Rivers Provider Network All |
$609.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$196.06
|
| Rate for Payer: United Healthcare Commercial |
$690.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$153.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.06
|
| Rate for Payer: United Payors & United Providers UP&UP |
$755.16
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$200.06
|
| Rate for Payer: Zelis Auto |
$324.80
|
| Rate for Payer: Zelis Medicare |
$170.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$240.07
|
| Rate for Payer: Zelis Worker's Compensation |
$221.68
|
|
|
TRT INFUSION INITIAL HOUR
|
Facility
|
IP
|
$812.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
1996365
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$221.68 |
| Max. Negotiated Rate |
$771.40 |
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Cigna Commercial |
$690.20
|
| Rate for Payer: First Health Commercial |
$730.80
|
| Rate for Payer: First Health Workers Compensation |
$313.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$730.80
|
| Rate for Payer: GEHA Commercial |
$568.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$730.80
|
| Rate for Payer: Multiplan All |
$738.92
|
| Rate for Payer: OMNI Networks Commercial |
$568.40
|
| Rate for Payer: One Health Plan PPO/POS |
$730.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$771.40
|
| Rate for Payer: Three Rivers Provider Network All |
$609.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$755.16
|
| Rate for Payer: Zelis Auto |
$324.80
|
| Rate for Payer: Zelis Worker's Compensation |
$221.68
|
|
|
TRT INFUSION SEQUENTIAL UP TO 1 HOUR
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
1996367
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$44.49 |
| Max. Negotiated Rate |
$376.20 |
| 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 |
$237.60
|
| 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 |
$67.58
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$152.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$316.80
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| 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 |
$45.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| 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 |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$108.11
|
|
|
TRT INFUSION SEQUENTIAL UP TO 1 HOUR
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
7896367
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$44.49 |
| Max. Negotiated Rate |
$498.75 |
| 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 |
$315.00
|
| 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 |
$67.58
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$446.25
|
| Rate for Payer: First Health Commercial |
$472.50
|
| Rate for Payer: First Health Workers Compensation |
$202.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$472.50
|
| Rate for Payer: GEHA Commercial |
$420.00
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$472.50
|
| 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 |
$45.40
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$477.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$367.50
|
| Rate for Payer: One Health Plan PPO/POS |
$472.50
|
| 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 |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$498.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$393.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Commercial |
$446.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$488.25
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$210.00
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$143.32
|
|
|
TRT INFUSION SEQUENTIAL UP TO 1 HOUR
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
1996367
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$108.11 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$336.60
|
| Rate for Payer: First Health Commercial |
$356.40
|
| Rate for Payer: First Health Workers Compensation |
$152.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$356.40
|
| Rate for Payer: GEHA Commercial |
$277.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$356.40
|
| Rate for Payer: Multiplan All |
$360.36
|
| Rate for Payer: OMNI Networks Commercial |
$277.20
|
| Rate for Payer: One Health Plan PPO/POS |
$356.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$376.20
|
| Rate for Payer: Three Rivers Provider Network All |
$297.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$368.28
|
| Rate for Payer: Zelis Auto |
$158.40
|
| Rate for Payer: Zelis Worker's Compensation |
$108.11
|
|
|
TRT INFUSION SEQUENTIAL UP TO 1 HOUR
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
7896367
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$143.32 |
| Max. Negotiated Rate |
$498.75 |
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$446.25
|
| Rate for Payer: First Health Commercial |
$472.50
|
| Rate for Payer: First Health Workers Compensation |
$202.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$472.50
|
| Rate for Payer: GEHA Commercial |
$367.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$472.50
|
| Rate for Payer: Multiplan All |
$477.75
|
| Rate for Payer: OMNI Networks Commercial |
$367.50
|
| Rate for Payer: One Health Plan PPO/POS |
$472.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$498.75
|
| Rate for Payer: Three Rivers Provider Network All |
$393.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$488.25
|
| Rate for Payer: Zelis Auto |
$210.00
|
| Rate for Payer: Zelis Worker's Compensation |
$143.32
|
|
|
TRT INITIAL HYDRATION 31 MIN-1 HOUR
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
1996360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$200.66 |
| Max. Negotiated Rate |
$698.25 |
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$624.75
|
| Rate for Payer: First Health Commercial |
$661.50
|
| Rate for Payer: First Health Workers Compensation |
$283.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$661.50
|
| Rate for Payer: GEHA Commercial |
$514.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$661.50
|
| Rate for Payer: Multiplan All |
$668.85
|
| Rate for Payer: OMNI Networks Commercial |
$514.50
|
| Rate for Payer: One Health Plan PPO/POS |
$661.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$698.25
|
| Rate for Payer: Three Rivers Provider Network All |
$551.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$683.55
|
| Rate for Payer: Zelis Auto |
$294.00
|
| Rate for Payer: Zelis Worker's Compensation |
$200.66
|
|
|
TRT INITIAL HYDRATION 31 MIN-1 HOUR
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
1996360
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$89.94 |
| Max. Negotiated Rate |
$698.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$113.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$441.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$113.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$89.94
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$200.06
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$624.75
|
| Rate for Payer: First Health Commercial |
$661.50
|
| Rate for Payer: First Health Workers Compensation |
$283.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$661.50
|
| Rate for Payer: GEHA Commercial |
$588.00
|
| Rate for Payer: GEHA Medicare |
$200.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$661.50
|
| Rate for Payer: Humana ChoiceCare |
$220.07
|
| Rate for Payer: Humana Medicare Advantage |
$200.06
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$336.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$91.77
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$200.06
|
| Rate for Payer: Multiplan All |
$668.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$340.10
|
| Rate for Payer: OMNI Networks Commercial |
$514.50
|
| Rate for Payer: One Health Plan PPO/POS |
$661.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$105.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$91.77
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$200.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$698.25
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$400.12
|
| Rate for Payer: Three Rivers Provider Network All |
$551.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$196.06
|
| Rate for Payer: United Healthcare Commercial |
$624.75
|
| Rate for Payer: United Healthcare Managed Medicaid |
$91.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.06
|
| Rate for Payer: United Payors & United Providers UP&UP |
$683.55
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$200.06
|
| Rate for Payer: Zelis Auto |
$294.00
|
| Rate for Payer: Zelis Medicare |
$170.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$240.07
|
| Rate for Payer: Zelis Worker's Compensation |
$200.66
|
|
