|
PERIODIC PREVENTIVE MED EST PAT 40-64YR
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
23099396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
PERIODIC PREVENTIVE MED EST PAT 40-64YR
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
23099396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
PERIODIC PREVENTIVE MED EST PAT 5-11YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
23099393
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PREVENTIVE MED EST PAT 5-11YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
23099393
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PREVENTIVE MED EST PAT 65+YR
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
23099397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
PERIODIC PREVENTIVE MED EST PAT 65+YR
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
23099397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 12-1
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
7299394
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 12-1
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
7299394
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 1-4
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
7299392
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$45.24 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$104.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$139.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Humana ChoiceCare |
$45.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$104.40
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$153.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 1-4
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
7299392
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$121.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 18-3
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
7299395
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 18-3
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
7299395
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 5-11
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
7299393
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PREVENTIVE MED EST PATIENT 5-11
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
7299393
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PREV MED EST PATIENT 1-4YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
23099392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PREV MED EST PATIENT 1-4YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
23099392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
PERIODIC PRVNTVE MED EST PT 65YR & OLDER
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
7299397
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
PERIODIC PRVNTVE MED EST PT 65YR & OLDER
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
7299397
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE
|
Facility
|
IP
|
$1,816.00
|
|
| Hospital Charge Code |
8149084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$495.77 |
| Max. Negotiated Rate |
$1,725.20 |
| Rate for Payer: Cash Price |
$1,089.60
|
| Rate for Payer: Cigna Commercial |
$1,543.60
|
| Rate for Payer: First Health Commercial |
$1,634.40
|
| Rate for Payer: First Health Workers Compensation |
$701.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,634.40
|
| Rate for Payer: GEHA Commercial |
$1,271.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,634.40
|
| Rate for Payer: Multiplan All |
$1,652.56
|
| Rate for Payer: OMNI Networks Commercial |
$1,271.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,634.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,725.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,362.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,688.88
|
| Rate for Payer: Zelis Auto |
$726.40
|
| Rate for Payer: Zelis Worker's Compensation |
$495.77
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE
|
Facility
|
IP
|
$4,106.00
|
|
|
Service Code
|
CPT 49084
|
| Hospital Charge Code |
1000036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,120.94 |
| Max. Negotiated Rate |
$3,900.70 |
| Rate for Payer: Cash Price |
$2,463.60
|
| Rate for Payer: Cigna Commercial |
$3,490.10
|
| Rate for Payer: First Health Commercial |
$3,695.40
|
| Rate for Payer: First Health Workers Compensation |
$1,585.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,695.40
|
| Rate for Payer: GEHA Commercial |
$2,874.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,695.40
|
| Rate for Payer: Multiplan All |
$3,736.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,874.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,695.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,900.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,079.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,818.58
|
| Rate for Payer: Zelis Auto |
$1,642.40
|
| Rate for Payer: Zelis Worker's Compensation |
$1,120.94
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE
|
Facility
|
OP
|
$1,816.00
|
|
| Hospital Charge Code |
8149084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$454.00 |
| Max. Negotiated Rate |
$1,725.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,089.60
|
| Rate for Payer: Cash Price |
$1,089.60
|
| Rate for Payer: Cigna Commercial |
$1,543.60
|
| Rate for Payer: First Health Commercial |
$1,634.40
|
| Rate for Payer: First Health Workers Compensation |
$701.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,634.40
|
| Rate for Payer: GEHA Commercial |
$1,452.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,634.40
|
| Rate for Payer: Humana ChoiceCare |
$472.16
|
| Rate for Payer: Multiplan All |
$1,652.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,089.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,271.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,634.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,725.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,362.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,598.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$454.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,688.88
|
| Rate for Payer: Zelis Auto |
$726.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$908.00
|
| Rate for Payer: Zelis Worker's Compensation |
$495.77
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT 49084
|
| Hospital Charge Code |
6149084
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$94.19 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: First Health Commercial |
$310.50
|
| Rate for Payer: First Health Workers Compensation |
$133.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$310.50
|
| Rate for Payer: GEHA Commercial |
$241.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$310.50
|
| Rate for Payer: Multiplan All |
$313.95
|
| Rate for Payer: OMNI Networks Commercial |
$241.50
|
| Rate for Payer: One Health Plan PPO/POS |
$310.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$327.75
|
| Rate for Payer: Three Rivers Provider Network All |
$258.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$320.85
|
| Rate for Payer: Zelis Auto |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$94.19
|
|
|
PERITONEAL LAVAGE W/WO IMAGING GUIDANCE
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT 49084
|
| Hospital Charge Code |
6149084
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$94.19 |
| Max. Negotiated Rate |
$1,780.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$556.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$207.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$556.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$440.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$890.25
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: First Health Commercial |
$310.50
|
| Rate for Payer: First Health Workers Compensation |
$133.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$310.50
|
| Rate for Payer: GEHA Commercial |
$276.00
|
| Rate for Payer: GEHA Medicare |
$890.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$310.50
|
| Rate for Payer: Humana ChoiceCare |
$979.27
|
| Rate for Payer: Humana Medicare Advantage |
$890.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,495.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$449.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$890.25
|
| Rate for Payer: Multiplan All |
$313.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,513.42
|
| Rate for Payer: OMNI Networks Commercial |
$241.50
|
| Rate for Payer: One Health Plan PPO/POS |
$310.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$519.32
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$449.76
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$890.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$327.75
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,780.50
|
| Rate for Payer: Three Rivers Provider Network All |
$258.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$872.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$449.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$890.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$320.85
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$890.25
|
| Rate for Payer: Zelis Auto |
$138.00
|
| Rate for Payer: Zelis Medicare |
$756.71
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.30
|
| Rate for Payer: Zelis Worker's Compensation |
$94.19
|
|
|
PERMETHRIN 1% LOTION 59 ML
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 70000004101
|
| Hospital Charge Code |
3303126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$59.50
|
| Rate for Payer: First Health Commercial |
$63.00
|
| Rate for Payer: First Health Workers Compensation |
$27.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.00
|
| Rate for Payer: Humana ChoiceCare |
$18.20
|
| Rate for Payer: Multiplan All |
$63.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$42.00
|
| Rate for Payer: OMNI Networks Commercial |
$49.00
|
| Rate for Payer: One Health Plan PPO/POS |
$63.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$66.50
|
| Rate for Payer: Three Rivers Provider Network All |
$52.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$61.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$65.10
|
| Rate for Payer: Zelis Auto |
$28.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.11
|
|
|
PERMETHRIN 1% LOTION 59 ML
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 70000004101
|
| Hospital Charge Code |
3303126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.11 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$59.50
|
| Rate for Payer: First Health Commercial |
$63.00
|
| Rate for Payer: First Health Workers Compensation |
$27.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.00
|
| Rate for Payer: GEHA Commercial |
$49.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.00
|
| Rate for Payer: Multiplan All |
$63.70
|
| Rate for Payer: OMNI Networks Commercial |
$49.00
|
| Rate for Payer: One Health Plan PPO/POS |
$63.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$66.50
|
| Rate for Payer: Three Rivers Provider Network All |
$52.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$65.10
|
| Rate for Payer: Zelis Auto |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.11
|
|
