|
TELEMED OFFICE VISIT LEVEL 5 COMPL COMP
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
23500082
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$170.62 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: First Health Workers Compensation |
$241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$437.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
| Rate for Payer: Zelis Worker's Compensation |
$170.62
|
|
|
TELEMED OFFICE VISIT LEVEL 5 COMPL COMP
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8600023
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$156.25 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: First Health Workers Compensation |
$241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$500.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Humana ChoiceCare |
$162.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$375.00
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$550.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$312.50
|
| Rate for Payer: Zelis Worker's Compensation |
$170.62
|
|
|
TELEMED OFFICE VISIT LEVEL 5 COMPL COMP
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8700016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$170.62 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: First Health Workers Compensation |
$241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$437.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
| Rate for Payer: Zelis Worker's Compensation |
$170.62
|
|
|
TELEMED OFFICE VISIT LEVEL 5 COMPL COMP
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8700016
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$156.25 |
| Max. Negotiated Rate |
$593.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$531.25
|
| Rate for Payer: First Health Commercial |
$562.50
|
| Rate for Payer: First Health Workers Compensation |
$241.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$562.50
|
| Rate for Payer: GEHA Commercial |
$500.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$562.50
|
| Rate for Payer: Humana ChoiceCare |
$162.50
|
| Rate for Payer: Multiplan All |
$568.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$375.00
|
| Rate for Payer: OMNI Networks Commercial |
$437.50
|
| Rate for Payer: One Health Plan PPO/POS |
$562.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$593.75
|
| Rate for Payer: Three Rivers Provider Network All |
$468.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$550.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$581.25
|
| Rate for Payer: Zelis Auto |
$250.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$312.50
|
| Rate for Payer: Zelis Worker's Compensation |
$170.62
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
8500019
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
8600030
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
8600030
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
8500019
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
24599243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
24599243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
7900012
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21699243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21900208
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21500024
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21900208
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21700054
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21700054
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
7900012
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21500024
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21000017
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21699243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
24799243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
21000017
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$187.20
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Humana ChoiceCare |
$81.12
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$187.20
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$274.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$156.00
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
25599243
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
|
TELEMED OFF/OTHR OP CONS NEW/ESTAB; 30 M
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
24799243
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$85.18 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$265.20
|
| Rate for Payer: First Health Commercial |
$280.80
|
| Rate for Payer: First Health Workers Compensation |
$120.46
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$280.80
|
| Rate for Payer: GEHA Commercial |
$218.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$280.80
|
| Rate for Payer: Multiplan All |
$283.92
|
| Rate for Payer: OMNI Networks Commercial |
$218.40
|
| Rate for Payer: One Health Plan PPO/POS |
$280.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$296.40
|
| Rate for Payer: Three Rivers Provider Network All |
$234.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$290.16
|
| Rate for Payer: Zelis Auto |
$124.80
|
| Rate for Payer: Zelis Worker's Compensation |
$85.18
|
|
