2020 CPT/HCPCS | 72126 |
Negotiated Private Fee | $400.00 |
Prossam | $260.00 |
Champva | $187.43 |
First Medical | $275.00 |
First Medical Vital | $139.78 |
Plan de Salud Menonita | $300.00 |
Menonita Vital | $186.78 |
Humana Gold plus/ Gold choice | Ambulatory Payment classification (APC) |
Humana | $285.00 |
Mapfre | $325.00 |
Mcs Classicare | $245.00 |
MCS Life | $280.00 |
Medicare | Ambulatory Payment classification (APC) |
MMM | $192.51 |
MMM Vital | $163.43 |
Panamerican Life | $350.00 |
PMC | $192.51 |
Tricare | $182.73 |
Triple S Salud | $275.00 |
Triple S Vital | $115.50 |
Triple S Advantage | Ambulatory Payment classification (APC) |
Negotiated Minimum Charge | $115.50 |
Negotiated Maximus Charge | $350.00 |
Discounted Cash Price | $320.00 |
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