|
SUB GRFT FSNHFGMD<100SQCM EA ADDL 25SQCM
|
Facility
|
IP
|
$3,007.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
1905289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$820.91 |
| Max. Negotiated Rate |
$2,856.65 |
| Rate for Payer: Cash Price |
$1,804.20
|
| Rate for Payer: Cigna Commercial |
$2,555.95
|
| Rate for Payer: First Health Commercial |
$2,706.30
|
| Rate for Payer: First Health Workers Compensation |
$1,161.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,706.30
|
| Rate for Payer: GEHA Commercial |
$2,104.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,706.30
|
| Rate for Payer: Multiplan All |
$2,736.37
|
| Rate for Payer: OMNI Networks Commercial |
$2,104.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,706.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,856.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,255.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,796.51
|
| Rate for Payer: Zelis Auto |
$1,202.80
|
| Rate for Payer: Zelis Worker's Compensation |
$820.91
|
|
|
SUBSEQUENT OBSERV - 15 MIN
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 99224
|
| Hospital Charge Code |
9899224
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$76.50
|
| Rate for Payer: First Health Commercial |
$81.00
|
| Rate for Payer: First Health Workers Compensation |
$34.75
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.00
|
| Rate for Payer: GEHA Commercial |
$63.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.00
|
| Rate for Payer: Multiplan All |
$81.90
|
| Rate for Payer: OMNI Networks Commercial |
$63.00
|
| Rate for Payer: One Health Plan PPO/POS |
$81.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$85.50
|
| Rate for Payer: Three Rivers Provider Network All |
$67.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$83.70
|
| Rate for Payer: Zelis Auto |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.57
|
|
|
SUBSEQUENT OBSERV - 30 MIN
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
CPT 99225
|
| Hospital Charge Code |
9899225
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$75.89 |
| Max. Negotiated Rate |
$264.10 |
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$236.30
|
| Rate for Payer: First Health Commercial |
$250.20
|
| Rate for Payer: First Health Workers Compensation |
$107.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$250.20
|
| Rate for Payer: GEHA Commercial |
$194.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$250.20
|
| Rate for Payer: Multiplan All |
$252.98
|
| Rate for Payer: OMNI Networks Commercial |
$194.60
|
| Rate for Payer: One Health Plan PPO/POS |
$250.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$264.10
|
| Rate for Payer: Three Rivers Provider Network All |
$208.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$258.54
|
| Rate for Payer: Zelis Auto |
$111.20
|
| Rate for Payer: Zelis Worker's Compensation |
$75.89
|
|
|
SUBSEQUENT OBSERV - HIGH
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
CPT 99226
|
| Hospital Charge Code |
9899226
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$69.07 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$215.05
|
| Rate for Payer: First Health Commercial |
$227.70
|
| Rate for Payer: First Health Workers Compensation |
$97.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$227.70
|
| Rate for Payer: GEHA Commercial |
$177.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$227.70
|
| Rate for Payer: Multiplan All |
$230.23
|
| Rate for Payer: OMNI Networks Commercial |
$177.10
|
| Rate for Payer: One Health Plan PPO/POS |
$227.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$240.35
|
| Rate for Payer: Three Rivers Provider Network All |
$189.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$235.29
|
| Rate for Payer: Zelis Auto |
$101.20
|
| Rate for Payer: Zelis Worker's Compensation |
$69.07
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
IP
|
$139.62
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
9899242
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$38.12 |
| Max. Negotiated Rate |
$132.64 |
| Rate for Payer: Cash Price |
$83.77
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: First Health Commercial |
$125.66
|
| Rate for Payer: First Health Workers Compensation |
$53.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$125.66
|
| Rate for Payer: GEHA Commercial |
$97.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$125.66
|
| Rate for Payer: Multiplan All |
$127.05
|
| Rate for Payer: OMNI Networks Commercial |
$97.73
|
| Rate for Payer: One Health Plan PPO/POS |
$125.66
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$132.64
|
| Rate for Payer: Three Rivers Provider Network All |
$104.72
|
| Rate for Payer: United Payors & United Providers UP&UP |
$129.85
|
| Rate for Payer: Zelis Auto |
$55.85
|
| Rate for Payer: Zelis Worker's Compensation |
$38.12
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
21999413
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$106.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$106.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$84.65
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$98.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Humana ChoiceCare |
$31.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$86.38
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.80
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$99.74
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$86.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$108.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
9899231
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$86.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
21799482
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$86.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
21999413
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$86.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
SUBSQ HOSP INPT OR OBS CARE PER DAY/25 M
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 99231
|
| Hospital Charge Code |
21799482
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$106.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$106.86
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$84.65
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$98.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Humana ChoiceCare |
$31.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$86.38
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.80
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$99.74
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$86.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$108.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.50
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
5099232
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
5099232
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$169.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.40
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Humana ChoiceCare |
$44.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.13
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$103.80
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$152.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$86.50
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
21799483
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$169.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.40
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Humana ChoiceCare |
$44.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.13
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$103.80
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$152.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$86.50
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
21799483
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
9899237
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
9899232
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
21999414
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$121.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/35 MI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 99232
|
| Hospital Charge Code |
21999414
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$169.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$103.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$169.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.40
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$147.05
|
| Rate for Payer: First Health Commercial |
$155.70
|
| Rate for Payer: First Health Workers Compensation |
$66.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$155.70
|
| Rate for Payer: GEHA Commercial |
$138.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$155.70
|
| Rate for Payer: Humana ChoiceCare |
$44.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.13
|
| Rate for Payer: Multiplan All |
$157.43
|
| Rate for Payer: New Mexico Health Connections Medicare |
$103.80
|
| Rate for Payer: OMNI Networks Commercial |
$121.10
|
| Rate for Payer: One Health Plan PPO/POS |
$155.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.34
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$164.35
|
| Rate for Payer: Three Rivers Provider Network All |
$129.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$152.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$160.89
|
| Rate for Payer: Zelis Auto |
$69.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$86.50
|
| Rate for Payer: Zelis Worker's Compensation |
$47.23
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 M
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
9899233
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
21799484
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
21999415
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$255.24 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$202.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$188.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Humana ChoiceCare |
$61.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$206.32
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$141.00
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$238.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$206.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$206.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.32
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.50
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
21799484
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$255.24 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$202.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$188.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Humana ChoiceCare |
$61.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$206.32
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$141.00
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$238.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$206.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$206.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.32
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.50
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
21999415
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
5099233
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
|
SUBSQ HOSP I/P OR OBS CARE PER DAY/50 MI
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 99233
|
| Hospital Charge Code |
5099233
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$255.24 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$255.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$202.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: First Health Workers Compensation |
$90.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$188.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Humana ChoiceCare |
$61.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$206.32
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$141.00
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$238.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$206.32
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$206.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.32
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.50
|
| Rate for Payer: Zelis Worker's Compensation |
$64.16
|
|
