|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
7699204
|
|
Hospital Revenue Code
|
511
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9299204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8799204
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8899204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8799204
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8499204
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8499204
|
|
Hospital Revenue Code
|
521
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8299204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8299204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9399204
|
|
Hospital Revenue Code
|
517
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
7699204
|
|
Hospital Revenue Code
|
511
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9699204
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
99204 OFC VIS NEW PT MOD MDM AT LEAST 45
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9399204
|
|
Hospital Revenue Code
|
517
|
| 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
|
|
|
99204 OFFICE VISIT LEVEL 4 EXTD COMP
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8699204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFFICE VISIT LEVEL 4 EXTD COMP
|
Facility
|
IP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8699204
|
|
Hospital Revenue Code
|
519
|
| 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
|
|
|
99204 OFFICE VISIT LEVEL 4 EXTD COMP
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
23500005
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
99204 OFFICE VISIT LEVEL 4 EXTD COMP
|
Facility
|
IP
|
$496.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
23500005
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8899205
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$160.25 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$384.60
|
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$512.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Humana ChoiceCare |
$166.66
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$384.60
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$564.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$160.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$320.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
9699205
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$174.99 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$448.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
9299205
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$160.25 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$384.60
|
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$512.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Humana ChoiceCare |
$166.66
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$384.60
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$564.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$160.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$320.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
9199205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$160.25 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$384.60
|
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$512.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Humana ChoiceCare |
$166.66
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$384.60
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$564.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$160.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$320.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
IP
|
$627.66
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8599205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$171.35 |
| Max. Negotiated Rate |
$596.28 |
| Rate for Payer: Cash Price |
$376.60
|
| Rate for Payer: Cigna Commercial |
$533.51
|
| Rate for Payer: First Health Commercial |
$564.89
|
| Rate for Payer: First Health Workers Compensation |
$242.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$564.89
|
| Rate for Payer: GEHA Commercial |
$439.36
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$564.89
|
| Rate for Payer: Multiplan All |
$571.17
|
| Rate for Payer: OMNI Networks Commercial |
$439.36
|
| Rate for Payer: One Health Plan PPO/POS |
$564.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$596.28
|
| Rate for Payer: Three Rivers Provider Network All |
$470.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$583.72
|
| Rate for Payer: Zelis Auto |
$251.06
|
| Rate for Payer: Zelis Worker's Compensation |
$171.35
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8499205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$174.99 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$448.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$627.66
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8599205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$156.91 |
| Max. Negotiated Rate |
$596.28 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$376.60
|
| Rate for Payer: Cash Price |
$376.60
|
| Rate for Payer: Cigna Commercial |
$533.51
|
| Rate for Payer: First Health Commercial |
$564.89
|
| Rate for Payer: First Health Workers Compensation |
$242.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$564.89
|
| Rate for Payer: GEHA Commercial |
$502.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$564.89
|
| Rate for Payer: Humana ChoiceCare |
$163.19
|
| Rate for Payer: Multiplan All |
$571.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$376.60
|
| Rate for Payer: OMNI Networks Commercial |
$439.36
|
| Rate for Payer: One Health Plan PPO/POS |
$564.89
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$596.28
|
| Rate for Payer: Three Rivers Provider Network All |
$470.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$552.34
|
| Rate for Payer: United Healthcare Managed Medicaid |
$156.91
|
| Rate for Payer: United Payors & United Providers UP&UP |
$583.72
|
| Rate for Payer: Zelis Auto |
$251.06
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$313.83
|
| Rate for Payer: Zelis Worker's Compensation |
$171.35
|
|
|
99205 NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
7699205
|
|
Hospital Revenue Code
|
511
|
| Min. Negotiated Rate |
$160.25 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$384.60
|
| Rate for Payer: Cash Price |
$384.60
|
| Rate for Payer: Cigna Commercial |
$544.85
|
| Rate for Payer: First Health Commercial |
$576.90
|
| Rate for Payer: First Health Workers Compensation |
$247.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$576.90
|
| Rate for Payer: GEHA Commercial |
$512.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$576.90
|
| Rate for Payer: Humana ChoiceCare |
$166.66
|
| Rate for Payer: Multiplan All |
$583.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$384.60
|
| Rate for Payer: OMNI Networks Commercial |
$448.70
|
| Rate for Payer: One Health Plan PPO/POS |
$576.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$608.95
|
| Rate for Payer: Three Rivers Provider Network All |
$480.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$564.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$160.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$596.13
|
| Rate for Payer: Zelis Auto |
$256.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$320.50
|
| Rate for Payer: Zelis Worker's Compensation |
$174.99
|
|
