|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8599209
|
|
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 |
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
|
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 |
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
|
|
|
TELEMED OFC VIS MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8200006
|
|
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 |
21000011
|
|
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 STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8599216
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
1900058
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9300006
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9600018
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
7600011
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9600018
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8400009
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8900039
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9300006
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
1900058
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8599216
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9599105
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8800056
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8800056
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8200008
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
9599105
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
20300166
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
TELEMED OFC VIS STR FWD MDM AT LEAST 10
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
7600011
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
