|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9599102
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$81.50 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$195.60
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$260.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Humana ChoiceCare |
$84.76
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$195.60
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$286.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
8400006
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$81.50 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$195.60
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$260.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Humana ChoiceCare |
$84.76
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$195.60
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$286.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
8200005
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$228.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9599102
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$228.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9600015
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$81.50 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$195.60
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$260.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Humana ChoiceCare |
$84.76
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$195.60
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$286.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS LOW MDM AT LEAST 30 MINS
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9600015
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$228.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8599209
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9600016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9300004
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8800054
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8400007
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$124.00 |
| Max. Negotiated Rate |
$471.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$297.60
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$421.60
|
| Rate for Payer: First Health Commercial |
$446.40
|
| Rate for Payer: First Health Workers Compensation |
$191.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$446.40
|
| Rate for Payer: GEHA Commercial |
$396.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$446.40
|
| Rate for Payer: Humana ChoiceCare |
$128.96
|
| Rate for Payer: Multiplan All |
$451.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$297.60
|
| Rate for Payer: OMNI Networks Commercial |
$347.20
|
| Rate for Payer: One Health Plan PPO/POS |
$446.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$471.20
|
| Rate for Payer: Three Rivers Provider Network All |
$372.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$436.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$461.28
|
| Rate for Payer: Zelis Auto |
$198.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$248.00
|
| Rate for Payer: Zelis Worker's Compensation |
$135.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8400007
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$135.41 |
| Max. Negotiated Rate |
$471.20 |
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cigna Commercial |
$421.60
|
| Rate for Payer: First Health Commercial |
$446.40
|
| Rate for Payer: First Health Workers Compensation |
$191.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$446.40
|
| Rate for Payer: GEHA Commercial |
$347.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$446.40
|
| Rate for Payer: Multiplan All |
$451.36
|
| Rate for Payer: OMNI Networks Commercial |
$347.20
|
| Rate for Payer: One Health Plan PPO/POS |
$446.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$471.20
|
| Rate for Payer: Three Rivers Provider Network All |
$372.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$461.28
|
| Rate for Payer: Zelis Auto |
$198.40
|
| Rate for Payer: Zelis Worker's Compensation |
$135.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8800054
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8900037
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9200037
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9200037
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9600016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9599103
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1900056
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9300004
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1900056
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
20300162
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$121.25 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.00
|
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$388.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Humana ChoiceCare |
$126.10
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$291.00
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$426.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$242.50
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9599103
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8900037
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
7600009
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$132.41 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Cash Price |
$291.00
|
| Rate for Payer: Cigna Commercial |
$412.25
|
| Rate for Payer: First Health Commercial |
$436.50
|
| Rate for Payer: First Health Workers Compensation |
$187.26
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$436.50
|
| Rate for Payer: GEHA Commercial |
$339.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$436.50
|
| Rate for Payer: Multiplan All |
$441.35
|
| Rate for Payer: OMNI Networks Commercial |
$339.50
|
| Rate for Payer: One Health Plan PPO/POS |
$436.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$460.75
|
| Rate for Payer: Three Rivers Provider Network All |
$363.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$451.05
|
| Rate for Payer: Zelis Auto |
$194.00
|
| Rate for Payer: Zelis Worker's Compensation |
$132.41
|
|
