|
EMLA 5 GM CREAM
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
3302048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$29.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Worker's Compensation |
$20.75
|
|
|
EMLA 5 GM CREAM
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
3302048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: First Health Workers Compensation |
$29.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$19.76
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$45.60
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$38.00
|
| Rate for Payer: Zelis Worker's Compensation |
$20.75
|
|
|
E/M NEW PATIENT AT LEAST 30 MINS - FACIL
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
1999203
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.50 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$195.60
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$260.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Humana ChoiceCare |
$84.76
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$195.60
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$286.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
E/M NEW PATIENT AT LEAST 30 MINS - FACIL
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
1999203
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$228.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
E/M NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
1991006
|
|
Hospital Revenue Code
|
982
|
| 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
|
|
|
E/M NEW PT HIGH MDM AT LEAST 60 MINS
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
1991006
|
|
Hospital Revenue Code
|
982
|
| 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
|
|
|
E/M NEW PT HIGH MDM AT LEAST 60 MINS - F
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
1999205
|
|
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
|
|
|
E/M NEW PT HIGH MDM AT LEAST 60 MINS - F
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
1999205
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
E/M NEW PT LOW MDM AT LEAST 30 MINS - PR
|
Facility
|
IP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
1991004
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$228.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
E/M NEW PT LOW MDM AT LEAST 30 MINS - PR
|
Facility
|
OP
|
$326.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
1991004
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$81.50 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$195.60
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$277.10
|
| Rate for Payer: First Health Commercial |
$293.40
|
| Rate for Payer: First Health Workers Compensation |
$125.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$293.40
|
| Rate for Payer: GEHA Commercial |
$260.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$293.40
|
| Rate for Payer: Humana ChoiceCare |
$84.76
|
| Rate for Payer: Multiplan All |
$296.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$195.60
|
| Rate for Payer: OMNI Networks Commercial |
$228.20
|
| Rate for Payer: One Health Plan PPO/POS |
$293.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$309.70
|
| Rate for Payer: Three Rivers Provider Network All |
$244.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$286.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$303.18
|
| Rate for Payer: Zelis Auto |
$130.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$163.00
|
| Rate for Payer: Zelis Worker's Compensation |
$89.00
|
|
|
E/M NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1991005
|
|
Hospital Revenue Code
|
982
|
| 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
|
|
|
E/M NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
IP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1999204
|
|
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
|
|
|
E/M NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1999204
|
|
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
|
|
|
E/M NEW PT MOD MDM AT LEAST 45 MINS
|
Facility
|
OP
|
$485.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
1991005
|
|
Hospital Revenue Code
|
982
|
| 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
|
|
|
E/M NP STRFWD MDM AT LEAST 15 MINS - FAC
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
1999202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$146.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
E/M NP STRFWD MDM AT LEAST 15 MINS - FAC
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
1999202
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.25 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$167.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Humana ChoiceCare |
$54.34
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.40
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.50
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
E/M NP STRFWD MDM AT LEAST 15 MINS - PRO
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
1991003
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$52.25 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$167.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Humana ChoiceCare |
$54.34
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$125.40
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.50
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
E/M NP STRFWD MDM AT LEAST 15 MINS - PRO
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
1991003
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$57.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: First Health Workers Compensation |
$80.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$188.10
|
| Rate for Payer: GEHA Commercial |
$146.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$188.10
|
| Rate for Payer: Multiplan All |
$190.19
|
| Rate for Payer: OMNI Networks Commercial |
$146.30
|
| Rate for Payer: One Health Plan PPO/POS |
$188.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$198.55
|
| Rate for Payer: Three Rivers Provider Network All |
$156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$194.37
|
| Rate for Payer: Zelis Auto |
$83.60
|
| Rate for Payer: Zelis Worker's Compensation |
$57.06
|
|
|
EMPAGLIFLOZIN 25 MG TAB
|
Facility
|
OP
|
$134.65
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
3303186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.66 |
| Max. Negotiated Rate |
$127.92 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$80.79
|
| Rate for Payer: Cash Price |
$80.79
|
| Rate for Payer: Cigna Commercial |
$114.45
|
| Rate for Payer: First Health Commercial |
$121.19
|
| Rate for Payer: First Health Workers Compensation |
$51.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$121.19
|
| Rate for Payer: GEHA Commercial |
$107.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$121.19
|
| Rate for Payer: Humana ChoiceCare |
$35.01
|
| Rate for Payer: Multiplan All |
$122.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$80.79
|
| Rate for Payer: OMNI Networks Commercial |
$94.25
|
| Rate for Payer: One Health Plan PPO/POS |
$121.19
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$127.92
|
| Rate for Payer: Three Rivers Provider Network All |
$100.99
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$118.49
|
| Rate for Payer: United Healthcare Managed Medicaid |
$33.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$125.22
|
| Rate for Payer: Zelis Auto |
$53.86
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$67.33
|
| Rate for Payer: Zelis Worker's Compensation |
$36.76
|
|
|
EMPAGLIFLOZIN 25 MG TAB
|
Facility
|
IP
|
$134.65
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
3303186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$127.92 |
| Rate for Payer: Cash Price |
$80.79
|
| Rate for Payer: Cigna Commercial |
$114.45
|
| Rate for Payer: First Health Commercial |
$121.19
|
| Rate for Payer: First Health Workers Compensation |
$51.99
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$121.19
|
| Rate for Payer: GEHA Commercial |
$94.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$121.19
|
| Rate for Payer: Multiplan All |
$122.53
|
| Rate for Payer: OMNI Networks Commercial |
$94.25
|
| Rate for Payer: One Health Plan PPO/POS |
$121.19
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$127.92
|
| Rate for Payer: Three Rivers Provider Network All |
$100.99
|
| Rate for Payer: United Payors & United Providers UP&UP |
$125.22
|
| Rate for Payer: Zelis Auto |
$53.86
|
| Rate for Payer: Zelis Worker's Compensation |
$36.76
|
|
|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
IP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
7299417
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$72.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
IP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
20399417
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$72.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
OP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
7299417
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$62.09
|
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$82.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Humana ChoiceCare |
$26.90
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.09
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$91.06
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.74
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
OP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
8599417
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$62.09
|
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$82.78
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Humana ChoiceCare |
$26.90
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$62.09
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$91.06
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.87
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.74
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
|
E/M PROLONGED SVCS; EA 15 MINS
|
Facility
|
IP
|
$103.48
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
8599417
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$98.31 |
| Rate for Payer: Cash Price |
$62.09
|
| Rate for Payer: Cigna Commercial |
$87.96
|
| Rate for Payer: First Health Commercial |
$93.13
|
| Rate for Payer: First Health Workers Compensation |
$39.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$93.13
|
| Rate for Payer: GEHA Commercial |
$72.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$93.13
|
| Rate for Payer: Multiplan All |
$94.17
|
| Rate for Payer: OMNI Networks Commercial |
$72.44
|
| Rate for Payer: One Health Plan PPO/POS |
$93.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$98.31
|
| Rate for Payer: Three Rivers Provider Network All |
$77.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$96.24
|
| Rate for Payer: Zelis Auto |
$41.39
|
| Rate for Payer: Zelis Worker's Compensation |
$28.25
|
|
