|
99391 EST PAT INF REEVAL (0-1 YR)
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
25500072
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 EST PAT INF REEVAL (0-1 YR)
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
8599391
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 EST PAT INF REEVAL (0-1 YR)
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21599391
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 EST PAT INF REEVAL (0-1 YR)
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21600072
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 EST PAT INF REEVAL (0-1 YR)
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21599391
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 PERIODIC PREVENT MED ESTAB PT <1YR
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21999391
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 PERIODIC PREVENT MED ESTAB PT <1YR
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21999391
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 PERIODIC PREVENT MED ESTAB PT <1YR
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21799462
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99391 PERIODIC PREVENT MED ESTAB PT <1YR
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
21799462
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21599392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.24 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$104.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$139.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Humana ChoiceCare |
$45.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$104.40
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$153.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21599392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$121.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21600073
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$45.24 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$104.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$139.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Humana ChoiceCare |
$45.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$104.40
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$153.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
25500073
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$121.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21600073
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$121.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 EST PAT REEVAL (1-4 YR)
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
25500073
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.24 |
| Max. Negotiated Rate |
$170.16 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$104.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$147.90
|
| Rate for Payer: First Health Commercial |
$156.60
|
| Rate for Payer: First Health Workers Compensation |
$67.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$156.60
|
| Rate for Payer: GEHA Commercial |
$139.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$156.60
|
| Rate for Payer: Humana ChoiceCare |
$45.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$158.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$104.40
|
| Rate for Payer: OMNI Networks Commercial |
$121.80
|
| Rate for Payer: One Health Plan PPO/POS |
$156.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$165.30
|
| Rate for Payer: Three Rivers Provider Network All |
$130.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$153.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$161.82
|
| Rate for Payer: Zelis Auto |
$69.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$87.00
|
| Rate for Payer: Zelis Worker's Compensation |
$47.50
|
|
|
99392 PERIODIC PREVENT MED EST PT 1-4YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21999392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99392 PERIODIC PREVENT MED EST PT 1-4YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21799463
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99392 PERIODIC PREVENT MED EST PT 1-4YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21799463
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99392 PERIODIC PREVENT MED EST PT 1-4YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
21999392
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
25500074
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
25500074
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21600074
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21600074
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21599393
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$170.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$134.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$151.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Humana ChoiceCare |
$49.14
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$113.40
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$158.82
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$137.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$166.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$94.50
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
|
99393 EST PAT REEVAL (5-11 YR)
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21599393
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$160.65
|
| Rate for Payer: First Health Commercial |
$170.10
|
| Rate for Payer: First Health Workers Compensation |
$72.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$170.10
|
| Rate for Payer: GEHA Commercial |
$132.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$170.10
|
| Rate for Payer: Multiplan All |
$171.99
|
| Rate for Payer: OMNI Networks Commercial |
$132.30
|
| Rate for Payer: One Health Plan PPO/POS |
$170.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$179.55
|
| Rate for Payer: Three Rivers Provider Network All |
$141.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$175.77
|
| Rate for Payer: Zelis Auto |
$75.60
|
| Rate for Payer: Zelis Worker's Compensation |
$51.60
|
|
