|
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
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21599396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21599396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
25500077
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21600077
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
25500077
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 EST PAT REEVAL (40-64 YR)
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21600077
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21999396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21799467
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
23500035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21799467
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$240.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Humana ChoiceCare |
$78.26
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.60
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$264.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.50
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
21999396
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99396 PERIODIC PREVENT MED EST PT 40-64Y
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
23500035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$255.85
|
| Rate for Payer: First Health Commercial |
$270.90
|
| Rate for Payer: First Health Workers Compensation |
$116.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$270.90
|
| Rate for Payer: GEHA Commercial |
$210.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$270.90
|
| Rate for Payer: Multiplan All |
$273.91
|
| Rate for Payer: OMNI Networks Commercial |
$210.70
|
| Rate for Payer: One Health Plan PPO/POS |
$270.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$285.95
|
| Rate for Payer: Three Rivers Provider Network All |
$225.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$279.93
|
| Rate for Payer: Zelis Auto |
$120.40
|
| Rate for Payer: Zelis Worker's Compensation |
$82.17
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
25500078
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21600078
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
25500078
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21599397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21600078
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 EST PAT REEVAL (65 YR AND OLDER)
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21599397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21799468
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21999397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21999397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
23500036
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$273.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Humana ChoiceCare |
$88.92
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$205.20
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$300.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$85.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$171.00
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
23500036
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
|
99397 PERIODIC PREVENT MED EST PT 65+YR
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
21799468
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.37 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: First Health Workers Compensation |
$132.05
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$307.80
|
| Rate for Payer: GEHA Commercial |
$239.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$307.80
|
| Rate for Payer: Multiplan All |
$311.22
|
| Rate for Payer: OMNI Networks Commercial |
$239.40
|
| Rate for Payer: One Health Plan PPO/POS |
$307.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$324.90
|
| Rate for Payer: Three Rivers Provider Network All |
$256.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$318.06
|
| Rate for Payer: Zelis Auto |
$136.80
|
| Rate for Payer: Zelis Worker's Compensation |
$93.37
|
|
