|
99393 PERIODIC PREVENT MED EST PT 5-11YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21999393
|
|
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 PERIODIC PREVENT MED EST PT 5-11YR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21799464
|
|
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 PERIODIC PREVENT MED EST PT 5-11YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21799464
|
|
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 PERIODIC PREVENT MED EST PT 5-11YR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
21999393
|
|
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
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
25500075
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21599394
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21600075
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| 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 |
$122.40
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| 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 |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
25500075
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| 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 |
$122.40
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| 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 |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21600075
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 EST PAT REEVAL (12-17 YR)
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21599394
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| 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 |
$122.40
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| 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 |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 PERIODIC PREVENT MED EST PT 12-17Y
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21999394
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 PERIODIC PREVENT MED EST PT 12-17Y
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21799465
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$142.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 PERIODIC PREVENT MED EST PT 12-17Y
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21799465
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| 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 |
$122.40
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| 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 |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99394 PERIODIC PREVENT MED EST PT 12-17Y
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
21999394
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$193.80 |
| 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 |
$122.40
|
| 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 |
$122.40
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cigna Commercial |
$173.40
|
| Rate for Payer: First Health Commercial |
$183.60
|
| Rate for Payer: First Health Workers Compensation |
$78.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$183.60
|
| Rate for Payer: GEHA Commercial |
$163.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$183.60
|
| Rate for Payer: Humana ChoiceCare |
$53.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$185.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$122.40
|
| Rate for Payer: OMNI Networks Commercial |
$142.80
|
| Rate for Payer: One Health Plan PPO/POS |
$183.60
|
| 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 |
$193.80
|
| Rate for Payer: Three Rivers Provider Network All |
$153.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$179.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$189.72
|
| Rate for Payer: Zelis Auto |
$81.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$102.00
|
| Rate for Payer: Zelis Worker's Compensation |
$55.69
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21599395
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21599395
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| 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 |
$165.60
|
| 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 |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| 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 |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
25500076
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21600076
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| 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 |
$165.60
|
| 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 |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| 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 |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21600076
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 EST PAT REEVAL (18-39 YR)
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
25500076
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| 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 |
$165.60
|
| 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 |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| 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 |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 PERIODIC PREVENT MED EST PT 18-39Y
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
23500034
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| 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 |
$165.60
|
| 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 |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| 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 |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 PERIODIC PREVENT MED EST PT 18-39Y
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21799466
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$262.20 |
| 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 |
$165.60
|
| 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 |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$220.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Humana ChoiceCare |
$71.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$165.60
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| 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 |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$242.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.00
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 PERIODIC PREVENT MED EST PT 18-39Y
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21799466
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 PERIODIC PREVENT MED EST PT 18-39Y
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
23500034
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
|
99395 PERIODIC PREVENT MED EST PT 18-39Y
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
21999395
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$234.60
|
| Rate for Payer: First Health Commercial |
$248.40
|
| Rate for Payer: First Health Workers Compensation |
$106.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$248.40
|
| Rate for Payer: GEHA Commercial |
$193.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$248.40
|
| Rate for Payer: Multiplan All |
$251.16
|
| Rate for Payer: OMNI Networks Commercial |
$193.20
|
| Rate for Payer: One Health Plan PPO/POS |
$248.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$262.20
|
| Rate for Payer: Three Rivers Provider Network All |
$207.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$256.68
|
| Rate for Payer: Zelis Auto |
$110.40
|
| Rate for Payer: Zelis Worker's Compensation |
$75.35
|
|
