|
DOMICIL/REST HOME NEW PT VISIT HI SEVER
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT 99327
|
| Hospital Charge Code |
8599327
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$159.43 |
| Max. Negotiated Rate |
$554.80 |
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$496.40
|
| Rate for Payer: First Health Commercial |
$525.60
|
| Rate for Payer: First Health Workers Compensation |
$225.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$525.60
|
| Rate for Payer: GEHA Commercial |
$408.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$525.60
|
| Rate for Payer: Multiplan All |
$531.44
|
| Rate for Payer: OMNI Networks Commercial |
$408.80
|
| Rate for Payer: One Health Plan PPO/POS |
$525.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$554.80
|
| Rate for Payer: Three Rivers Provider Network All |
$438.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$543.12
|
| Rate for Payer: Zelis Auto |
$233.60
|
| Rate for Payer: Zelis Worker's Compensation |
$159.43
|
|
|
DOMICIL/REST HOME NEW PT VISIT HI SEVER
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT 99327
|
| Hospital Charge Code |
8599327
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$146.00 |
| Max. Negotiated Rate |
$554.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$350.40
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$496.40
|
| Rate for Payer: First Health Commercial |
$525.60
|
| Rate for Payer: First Health Workers Compensation |
$225.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$525.60
|
| Rate for Payer: GEHA Commercial |
$467.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$525.60
|
| Rate for Payer: Humana ChoiceCare |
$151.84
|
| Rate for Payer: Multiplan All |
$531.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$350.40
|
| Rate for Payer: OMNI Networks Commercial |
$408.80
|
| Rate for Payer: One Health Plan PPO/POS |
$525.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$554.80
|
| Rate for Payer: Three Rivers Provider Network All |
$438.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$513.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$146.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$543.12
|
| Rate for Payer: Zelis Auto |
$233.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$292.00
|
| Rate for Payer: Zelis Worker's Compensation |
$159.43
|
|
|
DOMICIL/REST HOME NEW PT VISIT LOW SEVER
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 99324
|
| Hospital Charge Code |
8599324
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$48.59 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: First Health Workers Compensation |
$68.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$124.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
| Rate for Payer: Zelis Worker's Compensation |
$48.59
|
|
|
DOMICIL/REST HOME NEW PT VISIT LOW SEVER
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 99324
|
| Hospital Charge Code |
8599324
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: First Health Workers Compensation |
$68.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$142.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Humana ChoiceCare |
$46.28
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$106.80
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$156.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$44.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$89.00
|
| Rate for Payer: Zelis Worker's Compensation |
$48.59
|
|
|
DOMICIL/REST HOME NEW PT VISIT MOD SEVER
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 99325
|
| Hospital Charge Code |
8599325
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: First Health Workers Compensation |
$98.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$203.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Humana ChoiceCare |
$66.04
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$152.40
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$127.00
|
| Rate for Payer: Zelis Worker's Compensation |
$69.34
|
|
|
DOMICIL/REST HOME NEW PT VISIT MOD SEVER
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT 99325
|
| Hospital Charge Code |
8599325
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$69.34 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: First Health Workers Compensation |
$98.07
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$177.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
| Rate for Payer: Zelis Worker's Compensation |
$69.34
|
|
|
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 99335
|
| Hospital Charge Code |
8599335
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$76.25 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Humana ChoiceCare |
$79.30
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$183.00
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$268.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$152.50
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 99335
|
| Hospital Charge Code |
8599335
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$83.27 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: First Health Workers Compensation |
$117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Worker's Compensation |
$83.27
|
|
|
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
CPT 99336
|
| Hospital Charge Code |
8599336
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$107.75 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$258.60
|
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cigna Commercial |
$366.35
|
| Rate for Payer: First Health Commercial |
$387.90
|
| Rate for Payer: First Health Workers Compensation |
$166.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.90
|
| Rate for Payer: GEHA Commercial |
$344.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Humana ChoiceCare |
$112.06
|
| Rate for Payer: Multiplan All |
$392.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$258.60
|
| Rate for Payer: OMNI Networks Commercial |
$301.70
|
| Rate for Payer: One Health Plan PPO/POS |
$387.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$409.45
|
| Rate for Payer: Three Rivers Provider Network All |
$323.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$107.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$215.50
|
| Rate for Payer: Zelis Worker's Compensation |
$117.66
|
|
|
DOM/R-HOME E/M EST PT MOD HI SEVERITY 40
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
CPT 99336
|
| Hospital Charge Code |
8599336
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$117.66 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cigna Commercial |
$366.35
|
| Rate for Payer: First Health Commercial |
$387.90
|
| Rate for Payer: First Health Workers Compensation |
$166.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.90
|
| Rate for Payer: GEHA Commercial |
$301.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Multiplan All |
$392.21
|
| Rate for Payer: OMNI Networks Commercial |
$301.70
|
| Rate for Payer: One Health Plan PPO/POS |
$387.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$409.45
|
| Rate for Payer: Three Rivers Provider Network All |
$323.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
| Rate for Payer: Zelis Worker's Compensation |
$117.66
|
|
|
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 99334
|
| Hospital Charge Code |
8599334
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$78.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$162.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Humana ChoiceCare |
$52.78
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.80
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$178.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$101.50
|
| Rate for Payer: Zelis Worker's Compensation |
$55.42
|
|
|
DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 99334
|
| Hospital Charge Code |
8599334
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$55.42 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: First Health Workers Compensation |
$78.38
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$142.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Worker's Compensation |
$55.42
|
|
|
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
CPT 99337
|
| Hospital Charge Code |
8599337
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$152.25 |
| Max. Negotiated Rate |
$578.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$517.65
|
| Rate for Payer: First Health Commercial |
$548.10
|
| Rate for Payer: First Health Workers Compensation |
$235.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$548.10
|
| Rate for Payer: GEHA Commercial |
$487.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$548.10
|
| Rate for Payer: Humana ChoiceCare |
$158.34
|
| Rate for Payer: Multiplan All |
$554.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$365.40
|
| Rate for Payer: OMNI Networks Commercial |
$426.30
|
| Rate for Payer: One Health Plan PPO/POS |
$548.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$578.55
|
| Rate for Payer: Three Rivers Provider Network All |
$456.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$535.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$152.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$566.37
|
| Rate for Payer: Zelis Auto |
$243.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$304.50
|
| Rate for Payer: Zelis Worker's Compensation |
$166.26
|
|
|
DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
CPT 99337
|
| Hospital Charge Code |
8599337
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$166.26 |
| Max. Negotiated Rate |
$578.55 |
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cigna Commercial |
$517.65
|
| Rate for Payer: First Health Commercial |
$548.10
|
| Rate for Payer: First Health Workers Compensation |
$235.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$548.10
|
| Rate for Payer: GEHA Commercial |
$426.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$548.10
|
| Rate for Payer: Multiplan All |
$554.19
|
| Rate for Payer: OMNI Networks Commercial |
$426.30
|
| Rate for Payer: One Health Plan PPO/POS |
$548.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$578.55
|
| Rate for Payer: Three Rivers Provider Network All |
$456.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$566.37
|
| Rate for Payer: Zelis Auto |
$243.60
|
| Rate for Payer: Zelis Worker's Compensation |
$166.26
|
|
|
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT 99328
|
| Hospital Charge Code |
8599328
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$171.25 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: First Health Workers Compensation |
$264.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$548.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Humana ChoiceCare |
$178.10
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$411.00
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$602.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$171.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$342.50
|
| Rate for Payer: Zelis Worker's Compensation |
$187.00
|
|
|
DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
CPT 99328
|
| Hospital Charge Code |
8599328
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$187.00 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: First Health Workers Compensation |
$264.48
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$479.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
| Rate for Payer: Zelis Worker's Compensation |
$187.00
|
|
|
DONEPEZIL HYDROCHLORIDE 10MG TAB
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 00904647861
|
| Hospital Charge Code |
3300273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$35.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
DONEPEZIL HYDROCHLORIDE 10MG TAB
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
NDC 00904647861
|
| Hospital Charge Code |
3300273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$42.50
|
| Rate for Payer: First Health Commercial |
$45.00
|
| Rate for Payer: First Health Workers Compensation |
$19.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$45.00
|
| Rate for Payer: GEHA Commercial |
$40.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$45.00
|
| Rate for Payer: Humana ChoiceCare |
$13.00
|
| Rate for Payer: Multiplan All |
$45.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$30.00
|
| Rate for Payer: OMNI Networks Commercial |
$35.00
|
| Rate for Payer: One Health Plan PPO/POS |
$45.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$47.50
|
| Rate for Payer: Three Rivers Provider Network All |
$37.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$44.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$46.50
|
| Rate for Payer: Zelis Auto |
$20.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$25.00
|
| Rate for Payer: Zelis Worker's Compensation |
$13.65
|
|
|
DONEPEZIL HYDROCHLORIDE 5MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
3300274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
DONEPEZIL HYDROCHLORIDE 5MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
3300274
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
DO NOT USE
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
90009445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$79.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$25.74
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.40
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$87.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.50
|
|
|
DO NOT USE
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
90009445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.20
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
|
|
DO NOT USE SELENIUM RBC REF
|
Facility
|
OP
|
$341.00
|
|
| Hospital Charge Code |
23000070
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.25 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$131.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$272.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| Rate for Payer: Humana ChoiceCare |
$88.66
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$204.60
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.08
|
| Rate for Payer: United Healthcare Commercial |
$289.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$170.50
|
| Rate for Payer: Zelis Worker's Compensation |
$93.09
|
|
|
DO NOT USE SELENIUM RBC REF
|
Facility
|
IP
|
$341.00
|
|
| Hospital Charge Code |
23000070
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.09 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$289.85
|
| Rate for Payer: First Health Commercial |
$306.90
|
| Rate for Payer: First Health Workers Compensation |
$131.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$306.90
|
| Rate for Payer: GEHA Commercial |
$238.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$306.90
|
| Rate for Payer: Multiplan All |
$310.31
|
| Rate for Payer: OMNI Networks Commercial |
$238.70
|
| Rate for Payer: One Health Plan PPO/POS |
$306.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$323.95
|
| Rate for Payer: Three Rivers Provider Network All |
$255.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$317.13
|
| Rate for Payer: Zelis Auto |
$136.40
|
| Rate for Payer: Zelis Worker's Compensation |
$93.09
|
|
|
DOPamine 400MG/250ML D5W PREMIX
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
3300275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$83.30
|
| Rate for Payer: First Health Commercial |
$88.20
|
| Rate for Payer: First Health Workers Compensation |
$37.84
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$88.20
|
| Rate for Payer: GEHA Commercial |
$0.91
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$88.20
|
| Rate for Payer: Humana ChoiceCare |
$25.48
|
| Rate for Payer: Multiplan All |
$89.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$58.80
|
| Rate for Payer: OMNI Networks Commercial |
$68.60
|
| Rate for Payer: One Health Plan PPO/POS |
$88.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$93.10
|
| Rate for Payer: Three Rivers Provider Network All |
$73.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$86.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$91.14
|
| Rate for Payer: Zelis Auto |
$39.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.00
|
| Rate for Payer: Zelis Worker's Compensation |
$26.75
|
|
