|
INITIAL OBSERVATION CARE/DAY 70 MINUTES
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 99220
|
| Hospital Charge Code |
21799474
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$146.06 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$454.75
|
| Rate for Payer: First Health Commercial |
$481.50
|
| Rate for Payer: First Health Workers Compensation |
$206.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$481.50
|
| Rate for Payer: GEHA Commercial |
$374.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$481.50
|
| Rate for Payer: Multiplan All |
$486.85
|
| Rate for Payer: OMNI Networks Commercial |
$374.50
|
| Rate for Payer: One Health Plan PPO/POS |
$481.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$508.25
|
| Rate for Payer: Three Rivers Provider Network All |
$401.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$497.55
|
| Rate for Payer: Zelis Auto |
$214.00
|
| Rate for Payer: Zelis Worker's Compensation |
$146.06
|
|
|
INITIAL OBSERVATION CARE/DAY 70 MINUTES
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 99220
|
| Hospital Charge Code |
8299220
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$146.06 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$454.75
|
| Rate for Payer: First Health Commercial |
$481.50
|
| Rate for Payer: First Health Workers Compensation |
$206.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$481.50
|
| Rate for Payer: GEHA Commercial |
$374.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$481.50
|
| Rate for Payer: Multiplan All |
$486.85
|
| Rate for Payer: OMNI Networks Commercial |
$374.50
|
| Rate for Payer: One Health Plan PPO/POS |
$481.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$508.25
|
| Rate for Payer: Three Rivers Provider Network All |
$401.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$497.55
|
| Rate for Payer: Zelis Auto |
$214.00
|
| Rate for Payer: Zelis Worker's Compensation |
$146.06
|
|
|
INITIAL OBSERVATION CARE/DAY 70 MINUTES
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 99220
|
| Hospital Charge Code |
21999405
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$146.06 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$454.75
|
| Rate for Payer: First Health Commercial |
$481.50
|
| Rate for Payer: First Health Workers Compensation |
$206.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$481.50
|
| Rate for Payer: GEHA Commercial |
$374.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$481.50
|
| Rate for Payer: Multiplan All |
$486.85
|
| Rate for Payer: OMNI Networks Commercial |
$374.50
|
| Rate for Payer: One Health Plan PPO/POS |
$481.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$508.25
|
| Rate for Payer: Three Rivers Provider Network All |
$401.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$497.55
|
| Rate for Payer: Zelis Auto |
$214.00
|
| Rate for Payer: Zelis Worker's Compensation |
$146.06
|
|
|
INITIAL OBSERVATION CARE/DAY 70 MINUTES
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
CPT 99220
|
| Hospital Charge Code |
21799474
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$133.75 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$454.75
|
| Rate for Payer: First Health Commercial |
$481.50
|
| Rate for Payer: First Health Workers Compensation |
$206.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$481.50
|
| Rate for Payer: GEHA Commercial |
$428.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$481.50
|
| Rate for Payer: Humana ChoiceCare |
$139.10
|
| Rate for Payer: Multiplan All |
$486.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$321.00
|
| Rate for Payer: OMNI Networks Commercial |
$374.50
|
| Rate for Payer: One Health Plan PPO/POS |
$481.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$508.25
|
| Rate for Payer: Three Rivers Provider Network All |
$401.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$470.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$133.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$497.55
|
| Rate for Payer: Zelis Auto |
$214.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$267.50
|
| Rate for Payer: Zelis Worker's Compensation |
$146.06
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
23500020
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$301.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$122.37
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$401.60
|
| Rate for Payer: GEHA Medicare |
$122.37
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Humana ChoiceCare |
$134.61
|
| Rate for Payer: Humana Medicare Advantage |
$122.37
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$205.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$122.37
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$208.03
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$122.37
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$244.74
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$125.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$122.37
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Medicare |
$104.01
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$146.84
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT G0402
|
| Hospital Charge Code |
23500020
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$137.05 |
| Max. Negotiated Rate |
$476.90 |
| Rate for Payer: Cash Price |
$301.20
|
| Rate for Payer: Cigna Commercial |
$426.70
|
| Rate for Payer: First Health Commercial |
$451.80
|
| Rate for Payer: First Health Workers Compensation |
$193.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$451.80
|
| Rate for Payer: GEHA Commercial |
$351.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$451.80
|
| Rate for Payer: Multiplan All |
$456.82
|
| Rate for Payer: OMNI Networks Commercial |
$351.40
|
| Rate for Payer: One Health Plan PPO/POS |
$451.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$476.90
|
| Rate for Payer: Three Rivers Provider Network All |
$376.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$466.86
|
| Rate for Payer: Zelis Auto |
$200.80
|
| Rate for Payer: Zelis Worker's Compensation |
$137.05
|
|
|
INITIAL PREVENTIVE MED NEW PAT 40-64YR
|
Facility
|
IP
|
$362.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
23099386
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$98.83 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$253.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
INITIAL PREVENTIVE MED NEW PAT 40-64YR
|
Facility
|
OP
|
$362.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
23099386
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$217.20
|
| Rate for Payer: Cash Price |
$217.20
|
| Rate for Payer: Cigna Commercial |
$307.70
|
| Rate for Payer: First Health Commercial |
$325.80
|
| Rate for Payer: First Health Workers Compensation |
$139.77
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$325.80
|
| Rate for Payer: GEHA Commercial |
$289.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$325.80
|
| Rate for Payer: Humana ChoiceCare |
$94.12
|
| Rate for Payer: Multiplan All |
$329.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$217.20
|
| Rate for Payer: OMNI Networks Commercial |
$253.40
|
| Rate for Payer: One Health Plan PPO/POS |
$325.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$343.90
|
| Rate for Payer: Three Rivers Provider Network All |
$271.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$318.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$90.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$336.66
|
| Rate for Payer: Zelis Auto |
$144.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$181.00
|
| Rate for Payer: Zelis Worker's Compensation |
$98.83
|
|
|
INITIAL PREVENTIVE MED NEW PATIENT 0-1YR
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
23099381
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.33 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$139.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
INITIAL PREVENTIVE MED NEW PATIENT 0-1YR
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
23099381
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$189.05 |
| 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 |
$119.40
|
| 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 |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$169.15
|
| Rate for Payer: First Health Commercial |
$179.10
|
| Rate for Payer: First Health Workers Compensation |
$76.83
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$179.10
|
| Rate for Payer: GEHA Commercial |
$159.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$179.10
|
| Rate for Payer: Humana ChoiceCare |
$51.74
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$181.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$119.40
|
| Rate for Payer: OMNI Networks Commercial |
$139.30
|
| Rate for Payer: One Health Plan PPO/POS |
$179.10
|
| 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 |
$189.05
|
| Rate for Payer: Three Rivers Provider Network All |
$149.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$175.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$185.07
|
| Rate for Payer: Zelis Auto |
$79.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$99.50
|
| Rate for Payer: Zelis Worker's Compensation |
$54.33
|
|
|
INITIAL PREVENTIVE MED NEW PT 12-17YR
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
23099384
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$171.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
INITIAL PREVENTIVE MED NEW PT 12-17YR
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
23099384
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$232.75 |
| 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 |
$147.00
|
| 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 |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$208.25
|
| Rate for Payer: First Health Commercial |
$220.50
|
| Rate for Payer: First Health Workers Compensation |
$94.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$220.50
|
| Rate for Payer: GEHA Commercial |
$196.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$220.50
|
| Rate for Payer: Humana ChoiceCare |
$63.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$222.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$147.00
|
| Rate for Payer: OMNI Networks Commercial |
$171.50
|
| Rate for Payer: One Health Plan PPO/POS |
$220.50
|
| 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 |
$232.75
|
| Rate for Payer: Three Rivers Provider Network All |
$183.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$215.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$227.85
|
| Rate for Payer: Zelis Auto |
$98.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$122.50
|
| Rate for Payer: Zelis Worker's Compensation |
$66.89
|
|
|
INITIAL PREVENTIVE MED NEW PT 1-4YR
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
23099382
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.64 |
| Max. Negotiated Rate |
$203.30 |
| 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 |
$128.40
|
| 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 |
$128.40
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$82.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$171.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Humana ChoiceCare |
$55.64
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$128.40
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| 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 |
$203.30
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$188.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$107.00
|
| Rate for Payer: Zelis Worker's Compensation |
$58.42
|
|
|
INITIAL PREVENTIVE MED NEW PT 1-4YR
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
23099382
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.42 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$82.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$149.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$203.30
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Worker's Compensation |
$58.42
|
|
|
INITIAL PREVENTIVE MED NEW PT 18-39YR
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
23099385
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.32 |
| Max. Negotiated Rate |
$315.40 |
| 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 |
$199.20
|
| 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 |
$199.20
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$298.80
|
| Rate for Payer: First Health Workers Compensation |
$128.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$298.80
|
| Rate for Payer: GEHA Commercial |
$265.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$298.80
|
| Rate for Payer: Humana ChoiceCare |
$86.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$302.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$199.20
|
| Rate for Payer: OMNI Networks Commercial |
$232.40
|
| Rate for Payer: One Health Plan PPO/POS |
$298.80
|
| 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 |
$315.40
|
| Rate for Payer: Three Rivers Provider Network All |
$249.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$292.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$308.76
|
| Rate for Payer: Zelis Auto |
$132.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$166.00
|
| Rate for Payer: Zelis Worker's Compensation |
$90.64
|
|
|
INITIAL PREVENTIVE MED NEW PT 18-39YR
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
23099385
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.64 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$298.80
|
| Rate for Payer: First Health Workers Compensation |
$128.19
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$298.80
|
| Rate for Payer: GEHA Commercial |
$232.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$298.80
|
| Rate for Payer: Multiplan All |
$302.12
|
| Rate for Payer: OMNI Networks Commercial |
$232.40
|
| Rate for Payer: One Health Plan PPO/POS |
$298.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$315.40
|
| Rate for Payer: Three Rivers Provider Network All |
$249.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$308.76
|
| Rate for Payer: Zelis Auto |
$132.80
|
| Rate for Payer: Zelis Worker's Compensation |
$90.64
|
|
|
INITIAL PREVENTIVE MED NEW PT 5-11YR
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
23099383
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.52 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$160.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
INITIAL PREVENTIVE MED NEW PT 5-11YR
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 99383
|
| Hospital Charge Code |
23099383
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$217.55 |
| 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 |
$137.40
|
| 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 |
$137.40
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Cigna Commercial |
$194.65
|
| Rate for Payer: First Health Commercial |
$206.10
|
| Rate for Payer: First Health Workers Compensation |
$88.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$206.10
|
| Rate for Payer: GEHA Commercial |
$183.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$206.10
|
| Rate for Payer: Humana ChoiceCare |
$59.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$137.55
|
| Rate for Payer: Multiplan All |
$208.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$137.40
|
| Rate for Payer: OMNI Networks Commercial |
$160.30
|
| Rate for Payer: One Health Plan PPO/POS |
$206.10
|
| 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 |
$217.55
|
| Rate for Payer: Three Rivers Provider Network All |
$171.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$201.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.97
|
| Rate for Payer: Zelis Auto |
$91.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.50
|
| Rate for Payer: Zelis Worker's Compensation |
$62.52
|
|
|
INITIAL PREVENTIV MED NEW PATIENT 65+YR
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
23099387
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$111.38 |
| Max. Negotiated Rate |
$387.60 |
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cigna Commercial |
$346.80
|
| Rate for Payer: First Health Commercial |
$367.20
|
| Rate for Payer: First Health Workers Compensation |
$157.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$367.20
|
| Rate for Payer: GEHA Commercial |
$285.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$367.20
|
| Rate for Payer: Multiplan All |
$371.28
|
| Rate for Payer: OMNI Networks Commercial |
$285.60
|
| Rate for Payer: One Health Plan PPO/POS |
$367.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$387.60
|
| Rate for Payer: Three Rivers Provider Network All |
$306.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$379.44
|
| Rate for Payer: Zelis Auto |
$163.20
|
| Rate for Payer: Zelis Worker's Compensation |
$111.38
|
|
|
INITIAL PREVENTIV MED NEW PATIENT 65+YR
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
23099387
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$387.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$244.80
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cigna Commercial |
$346.80
|
| Rate for Payer: First Health Commercial |
$367.20
|
| Rate for Payer: First Health Workers Compensation |
$157.53
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$367.20
|
| Rate for Payer: GEHA Commercial |
$326.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$367.20
|
| Rate for Payer: Humana ChoiceCare |
$106.08
|
| Rate for Payer: Multiplan All |
$371.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$244.80
|
| Rate for Payer: OMNI Networks Commercial |
$285.60
|
| Rate for Payer: One Health Plan PPO/POS |
$367.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$387.60
|
| Rate for Payer: Three Rivers Provider Network All |
$306.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$359.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$379.44
|
| Rate for Payer: Zelis Auto |
$163.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$204.00
|
| Rate for Payer: Zelis Worker's Compensation |
$111.38
|
|
|
INITIAL PSYCH CCM
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
CPT 99492
|
| Hospital Charge Code |
9199507
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$74.66 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$426.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$87.83
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cigna Commercial |
$604.35
|
| Rate for Payer: First Health Commercial |
$639.90
|
| Rate for Payer: First Health Workers Compensation |
$274.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.90
|
| Rate for Payer: GEHA Commercial |
$568.80
|
| Rate for Payer: GEHA Medicare |
$87.83
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.90
|
| Rate for Payer: Humana ChoiceCare |
$96.61
|
| Rate for Payer: Humana Medicare Advantage |
$87.83
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$147.55
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$87.83
|
| Rate for Payer: Multiplan All |
$647.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$149.31
|
| Rate for Payer: OMNI Networks Commercial |
$497.70
|
| Rate for Payer: One Health Plan PPO/POS |
$639.90
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$87.83
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$675.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$175.66
|
| Rate for Payer: Three Rivers Provider Network All |
$533.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$86.07
|
| Rate for Payer: United Healthcare Managed Medicaid |
$177.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.83
|
| Rate for Payer: United Payors & United Providers UP&UP |
$661.23
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$87.83
|
| Rate for Payer: Zelis Auto |
$284.40
|
| Rate for Payer: Zelis Medicare |
$74.66
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$105.40
|
| Rate for Payer: Zelis Worker's Compensation |
$194.10
|
|
|
INITIAL PSYCH CCM
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
CPT 99492
|
| Hospital Charge Code |
9199507
|
|
Hospital Revenue Code
|
529
|
| Min. Negotiated Rate |
$194.10 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cigna Commercial |
$604.35
|
| Rate for Payer: First Health Commercial |
$639.90
|
| Rate for Payer: First Health Workers Compensation |
$274.52
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.90
|
| Rate for Payer: GEHA Commercial |
$497.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.90
|
| Rate for Payer: Multiplan All |
$647.01
|
| Rate for Payer: OMNI Networks Commercial |
$497.70
|
| Rate for Payer: One Health Plan PPO/POS |
$639.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$675.45
|
| Rate for Payer: Three Rivers Provider Network All |
$533.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$661.23
|
| Rate for Payer: Zelis Auto |
$284.40
|
| Rate for Payer: Zelis Worker's Compensation |
$194.10
|
|
|
INITIAL TX 1ST DEGREE BURN LOCAL TX
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
8150036
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$467.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$295.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$418.20
|
| Rate for Payer: First Health Commercial |
$442.80
|
| Rate for Payer: First Health Workers Compensation |
$189.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$442.80
|
| Rate for Payer: GEHA Commercial |
$393.60
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$442.80
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$447.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$344.40
|
| Rate for Payer: One Health Plan PPO/POS |
$442.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$467.40
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$369.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$457.56
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$196.80
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$134.32
|
|
|
INITIAL TX 1ST DEGREE BURN LOCAL TX
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
20300014
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.42 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$82.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$149.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$203.30
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Worker's Compensation |
$58.42
|
|
|
INITIAL TX 1ST DEGREE BURN LOCAL TX
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
21600200
|
|
Hospital Revenue Code
|
517
|
| Min. Negotiated Rate |
$58.42 |
| Max. Negotiated Rate |
$377.34 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$128.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$147.69
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$188.67
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$181.90
|
| Rate for Payer: First Health Commercial |
$192.60
|
| Rate for Payer: First Health Workers Compensation |
$82.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$192.60
|
| Rate for Payer: GEHA Commercial |
$171.20
|
| Rate for Payer: GEHA Medicare |
$188.67
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$192.60
|
| Rate for Payer: Humana ChoiceCare |
$207.54
|
| Rate for Payer: Humana Medicare Advantage |
$188.67
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$316.97
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$119.38
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$188.67
|
| Rate for Payer: Multiplan All |
$194.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$320.74
|
| Rate for Payer: OMNI Networks Commercial |
$149.80
|
| Rate for Payer: One Health Plan PPO/POS |
$192.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$137.84
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$119.38
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$188.67
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$203.30
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$377.34
|
| Rate for Payer: Three Rivers Provider Network All |
$160.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$184.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.67
|
| Rate for Payer: United Payors & United Providers UP&UP |
$199.02
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$188.67
|
| Rate for Payer: Zelis Auto |
$85.60
|
| Rate for Payer: Zelis Medicare |
$160.37
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$226.40
|
| Rate for Payer: Zelis Worker's Compensation |
$58.42
|
|
