|
LONG ARM SPLINT, ADULT(11+YRS)
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
8204018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM SPLINT, ADULT(11+YRS)
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
8804018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$32.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM SPLINT, ADULT(11+YRS)
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
8204018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM SPLINT, ADULT(11+YRS)
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT Q4018
|
| Hospital Charge Code |
8804018
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$39.10
|
| Rate for Payer: First Health Commercial |
$41.40
|
| Rate for Payer: First Health Workers Compensation |
$17.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$41.40
|
| Rate for Payer: GEHA Commercial |
$36.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$41.40
|
| Rate for Payer: Humana ChoiceCare |
$11.96
|
| Rate for Payer: Multiplan All |
$41.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.60
|
| Rate for Payer: OMNI Networks Commercial |
$32.20
|
| Rate for Payer: One Health Plan PPO/POS |
$41.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$43.70
|
| Rate for Payer: Three Rivers Provider Network All |
$34.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$40.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$42.78
|
| Rate for Payer: Zelis Auto |
$18.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$23.00
|
| Rate for Payer: Zelis Worker's Compensation |
$12.56
|
|
|
LONG ARM SPLINT, PED (0-10 YRS)
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
8804020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
LONG ARM SPLINT, PED (0-10 YRS)
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
8204020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$20.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Humana ChoiceCare |
$6.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15.00
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12.50
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
LONG ARM SPLINT, PED (0-10 YRS)
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
8204020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
LONG ARM SPLINT, PED (0-10 YRS)
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT Q4020
|
| Hospital Charge Code |
8804020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$21.25
|
| Rate for Payer: First Health Commercial |
$22.50
|
| Rate for Payer: First Health Workers Compensation |
$9.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22.50
|
| Rate for Payer: GEHA Commercial |
$17.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22.50
|
| Rate for Payer: Multiplan All |
$22.75
|
| Rate for Payer: OMNI Networks Commercial |
$17.50
|
| Rate for Payer: One Health Plan PPO/POS |
$22.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$23.75
|
| Rate for Payer: Three Rivers Provider Network All |
$18.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23.25
|
| Rate for Payer: Zelis Auto |
$10.00
|
| Rate for Payer: Zelis Worker's Compensation |
$6.83
|
|
|
LONGITUDINAL ARCH SUPPORT
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8800020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
|
|
LONGITUDINAL ARCH SUPPORT
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8800020
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$45.75
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$46.68
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$53.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$46.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
|
|
LONGITUDINAL ARCH SUPPORT
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8230078
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
|
|
LONGITUDINAL ARCH SUPPORT
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT L3080
|
| Hospital Charge Code |
8230078
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$57.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$45.75
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$46.68
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$53.90
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$46.68
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$46.68
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
|
|
LONG LEG CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
CPT Q4030
|
| Hospital Charge Code |
8204030
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$63.61 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$198.05
|
| Rate for Payer: First Health Commercial |
$209.70
|
| Rate for Payer: First Health Workers Compensation |
$89.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$209.70
|
| Rate for Payer: GEHA Commercial |
$163.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$209.70
|
| Rate for Payer: Multiplan All |
$212.03
|
| Rate for Payer: OMNI Networks Commercial |
$163.10
|
| Rate for Payer: One Health Plan PPO/POS |
$209.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$221.35
|
| Rate for Payer: Three Rivers Provider Network All |
$174.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$216.69
|
| Rate for Payer: Zelis Auto |
$93.20
|
| Rate for Payer: Zelis Worker's Compensation |
$63.61
|
|
|
LONG LEG CAST, ADULT (11+YRS)
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
CPT Q4030
|
| Hospital Charge Code |
8804030
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$63.61 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$198.05
|
| Rate for Payer: First Health Commercial |
$209.70
|
| Rate for Payer: First Health Workers Compensation |
$89.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$209.70
|
| Rate for Payer: GEHA Commercial |
$163.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$209.70
|
| Rate for Payer: Multiplan All |
$212.03
|
| Rate for Payer: OMNI Networks Commercial |
$163.10
|
| Rate for Payer: One Health Plan PPO/POS |
$209.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$221.35
|
| Rate for Payer: Three Rivers Provider Network All |
$174.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$216.69
|
| Rate for Payer: Zelis Auto |
$93.20
|
| Rate for Payer: Zelis Worker's Compensation |
$63.61
|
|
|
LONG LEG CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
CPT Q4030
|
| Hospital Charge Code |
8204030
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$58.25 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$198.05
|
| Rate for Payer: First Health Commercial |
$209.70
|
| Rate for Payer: First Health Workers Compensation |
$89.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$209.70
|
| Rate for Payer: GEHA Commercial |
$186.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$209.70
|
| Rate for Payer: Humana ChoiceCare |
$60.58
|
| Rate for Payer: Multiplan All |
$212.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$139.80
|
| Rate for Payer: OMNI Networks Commercial |
$163.10
|
| Rate for Payer: One Health Plan PPO/POS |
$209.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$221.35
|
| Rate for Payer: Three Rivers Provider Network All |
$174.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$58.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$216.69
|
| Rate for Payer: Zelis Auto |
$93.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$116.50
|
| Rate for Payer: Zelis Worker's Compensation |
$63.61
|
|
|
LONG LEG CAST, ADULT (11+YRS)
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
CPT Q4030
|
| Hospital Charge Code |
8804030
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$58.25 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$198.05
|
| Rate for Payer: First Health Commercial |
$209.70
|
| Rate for Payer: First Health Workers Compensation |
$89.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$209.70
|
| Rate for Payer: GEHA Commercial |
$186.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$209.70
|
| Rate for Payer: Humana ChoiceCare |
$60.58
|
| Rate for Payer: Multiplan All |
$212.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$139.80
|
| Rate for Payer: OMNI Networks Commercial |
$163.10
|
| Rate for Payer: One Health Plan PPO/POS |
$209.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$221.35
|
| Rate for Payer: Three Rivers Provider Network All |
$174.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$205.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$58.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$216.69
|
| Rate for Payer: Zelis Auto |
$93.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$116.50
|
| Rate for Payer: Zelis Worker's Compensation |
$63.61
|
|
|
LONG LEG CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT Q4032
|
| Hospital Charge Code |
8204032
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.94 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$81.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
LONG LEG CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT Q4032
|
| Hospital Charge Code |
8804032
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$93.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Humana ChoiceCare |
$30.42
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.20
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$102.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$58.50
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
LONG LEG CAST, PED (0-10 YRS)
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT Q4032
|
| Hospital Charge Code |
8804032
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.94 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$81.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
LONG LEG CAST, PED (0-10 YRS)
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT Q4032
|
| Hospital Charge Code |
8204032
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$99.45
|
| Rate for Payer: First Health Commercial |
$105.30
|
| Rate for Payer: First Health Workers Compensation |
$45.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$105.30
|
| Rate for Payer: GEHA Commercial |
$93.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$105.30
|
| Rate for Payer: Humana ChoiceCare |
$30.42
|
| Rate for Payer: Multiplan All |
$106.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$70.20
|
| Rate for Payer: OMNI Networks Commercial |
$81.90
|
| Rate for Payer: One Health Plan PPO/POS |
$105.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$111.15
|
| Rate for Payer: Three Rivers Provider Network All |
$87.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$102.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$29.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$108.81
|
| Rate for Payer: Zelis Auto |
$46.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$58.50
|
| Rate for Payer: Zelis Worker's Compensation |
$31.94
|
|
|
LONG LEG SPLINT, ADULT (11+YRS)
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
8204042
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$85.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.20
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$94.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.50
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
LONG LEG SPLINT, ADULT (11+YRS)
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
8804042
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$85.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Humana ChoiceCare |
$27.82
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$64.20
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$94.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.50
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
LONG LEG SPLINT, ADULT (11+YRS)
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
8804042
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$74.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
LONG LEG SPLINT, ADULT (11+YRS)
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT Q4042
|
| Hospital Charge Code |
8204042
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$90.95
|
| Rate for Payer: First Health Commercial |
$96.30
|
| Rate for Payer: First Health Workers Compensation |
$41.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$96.30
|
| Rate for Payer: GEHA Commercial |
$74.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$96.30
|
| Rate for Payer: Multiplan All |
$97.37
|
| Rate for Payer: OMNI Networks Commercial |
$74.90
|
| Rate for Payer: One Health Plan PPO/POS |
$96.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$101.65
|
| Rate for Payer: Three Rivers Provider Network All |
$80.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$99.51
|
| Rate for Payer: Zelis Auto |
$42.80
|
| Rate for Payer: Zelis Worker's Compensation |
$29.21
|
|
|
LONG LEG SPLINT, PED (0-10 YRS)
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT Q4044
|
| Hospital Charge Code |
8204044
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$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 |
$21.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$50.40
|
| Rate for Payer: GEHA Commercial |
$44.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$50.40
|
| Rate for Payer: Humana ChoiceCare |
$14.56
|
| Rate for Payer: Multiplan All |
$50.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$33.60
|
| 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: TriWest Veterans Administration/VAPC3 |
$49.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$52.08
|
| Rate for Payer: Zelis Auto |
$22.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.29
|
|
