|
OTA ASSESS HLTH/BEHAVE, SUBSEQ
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
CPT 96151 GO,CO
|
| Hospital Charge Code |
4597809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$171.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$153.85
|
| Rate for Payer: First Health Commercial |
$162.90
|
| Rate for Payer: First Health Workers Compensation |
$69.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.90
|
| Rate for Payer: GEHA Commercial |
$144.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.90
|
| Rate for Payer: Humana ChoiceCare |
$47.06
|
| Rate for Payer: Multiplan All |
$164.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$108.60
|
| Rate for Payer: OMNI Networks Commercial |
$126.70
|
| Rate for Payer: One Health Plan PPO/POS |
$162.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.95
|
| Rate for Payer: Three Rivers Provider Network All |
$135.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$159.28
|
| Rate for Payer: United Healthcare Commercial |
$153.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$168.33
|
| Rate for Payer: Zelis Auto |
$72.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$90.50
|
| Rate for Payer: Zelis Worker's Compensation |
$49.41
|
|
|
OTA ASSESS HLTH/BEHAVE, SUBSEQ
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 96151 GO,CO
|
| Hospital Charge Code |
4597809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$171.95 |
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$153.85
|
| Rate for Payer: First Health Commercial |
$162.90
|
| Rate for Payer: First Health Workers Compensation |
$69.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.90
|
| Rate for Payer: GEHA Commercial |
$126.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.90
|
| Rate for Payer: Multiplan All |
$164.71
|
| Rate for Payer: OMNI Networks Commercial |
$126.70
|
| Rate for Payer: One Health Plan PPO/POS |
$162.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.95
|
| Rate for Payer: Three Rivers Provider Network All |
$135.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$168.33
|
| Rate for Payer: Zelis Auto |
$72.40
|
| Rate for Payer: Zelis Worker's Compensation |
$49.41
|
|
|
OTA ASSISTIVE TECHNOLOGY ASSESSMENT
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 97755 GO,CO
|
| Hospital Charge Code |
4597819
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$52.42 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$74.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Worker's Compensation |
$52.42
|
|
|
OTA ASSISTIVE TECHNOLOGY ASSESSMENT
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 97755 GO,CO
|
| Hospital Charge Code |
4597819
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$40.65 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$51.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$51.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$40.65
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$73.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$153.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Humana ChoiceCare |
$49.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$41.48
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$115.20
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$47.89
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$41.48
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$168.96
|
| Rate for Payer: United Healthcare Commercial |
$163.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$41.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$96.00
|
| Rate for Payer: Zelis Worker's Compensation |
$51.83
|
|
|
OTA BIOFEEDBACK TRAIN, ANY ME
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 90901 GO,CO
|
| Hospital Charge Code |
4597801
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$40.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Worker's Compensation |
$28.94
|
|
|
OTA BIOFEEDBACK TRAIN, ANY ME
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 90901 GO,CO
|
| Hospital Charge Code |
4597801
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: First Health Workers Compensation |
$76.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Commercial |
$90.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
| Rate for Payer: Zelis Worker's Compensation |
$54.16
|
|
|
OTA COGNITIVE SKILLS DEVELOPMENT
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT G0515 GO,CO
|
| Hospital Charge Code |
4500515
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$60.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
OTA COGNITIVE SKILLS DEVELOPMENT
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT G0515 GO,CO
|
| Hospital Charge Code |
4500515
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$73.10
|
| Rate for Payer: First Health Commercial |
$77.40
|
| Rate for Payer: First Health Workers Compensation |
$33.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$77.40
|
| Rate for Payer: GEHA Commercial |
$68.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$77.40
|
| Rate for Payer: Humana ChoiceCare |
$22.36
|
| Rate for Payer: Multiplan All |
$78.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$51.60
|
| Rate for Payer: OMNI Networks Commercial |
$60.20
|
| Rate for Payer: One Health Plan PPO/POS |
$77.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$81.70
|
| Rate for Payer: Three Rivers Provider Network All |
$64.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$75.68
|
| Rate for Payer: United Healthcare Commercial |
$73.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$79.98
|
| Rate for Payer: Zelis Auto |
$34.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$43.00
|
| Rate for Payer: Zelis Worker's Compensation |
$23.48
|
|
|
OTA COMM/WORK REINTEG
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT 97537 GO,CO
|
| Hospital Charge Code |
4597537
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$31.63 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$39.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$39.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$31.63
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$60.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$37.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.28
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.40
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$37.27
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.28
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$126.72
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.28
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.00
|
| Rate for Payer: Zelis Worker's Compensation |
$42.49
|
|
|
OTA COMM/WORK REINTEG
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT 97537 GO,CO
|
| Hospital Charge Code |
4597537
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: First Health Workers Compensation |
$55.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Worker's Compensation |
$39.31
|
|
|
OTA CONTRAST BATH THERAPY CONST ATTEND
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 97034 GO,CO
|
| Hospital Charge Code |
4597034
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: First Health Workers Compensation |
$43.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
| Rate for Payer: Zelis Worker's Compensation |
$30.58
|
|
|
OTA CONTRAST BATH THERAPY CONST ATTEND
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 97034 GO,CO
|
| Hospital Charge Code |
4597034
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$67.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.54
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: First Health Workers Compensation |
$26.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Humana ChoiceCare |
$29.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.02
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$67.20
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.56
|
| Rate for Payer: United Healthcare Commercial |
$95.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$56.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.68
|
|
|
OTA DEVELOPMENTAL SCREENING
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 96110 GO,CO
|
| Hospital Charge Code |
4597807
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$18.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$18.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$14.32
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$21.98
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$304.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Humana ChoiceCare |
$98.80
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14.61
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$228.00
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16.87
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$334.40
|
| Rate for Payer: United Healthcare Commercial |
$323.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$190.00
|
| Rate for Payer: Zelis Worker's Compensation |
$15.54
|
|
|
OTA DEVELOPMENTAL SCREENING
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 96110 GO,CO
|
| Hospital Charge Code |
4597807
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: First Health Workers Compensation |
$146.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$342.00
|
| Rate for Payer: GEHA Commercial |
$266.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$342.00
|
| Rate for Payer: Multiplan All |
$345.80
|
| Rate for Payer: OMNI Networks Commercial |
$266.00
|
| Rate for Payer: One Health Plan PPO/POS |
$342.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$361.00
|
| Rate for Payer: Three Rivers Provider Network All |
$285.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$353.40
|
| Rate for Payer: Zelis Auto |
$152.00
|
| Rate for Payer: Zelis Worker's Compensation |
$103.74
|
|
|
OTA DEVEL TST PHYS/QHP 1ST HOUR
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
CPT 96112 GO,CO
|
| Hospital Charge Code |
4596112
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$372.40 |
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$333.20
|
| Rate for Payer: First Health Commercial |
$352.80
|
| Rate for Payer: First Health Workers Compensation |
$151.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$352.80
|
| Rate for Payer: GEHA Commercial |
$274.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$352.80
|
| Rate for Payer: Multiplan All |
$356.72
|
| Rate for Payer: OMNI Networks Commercial |
$274.40
|
| Rate for Payer: One Health Plan PPO/POS |
$352.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$372.40
|
| Rate for Payer: Three Rivers Provider Network All |
$294.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$364.56
|
| Rate for Payer: Zelis Auto |
$156.80
|
| Rate for Payer: Zelis Worker's Compensation |
$107.02
|
|
|
OTA DEVEL TST PHYS/QHP 1ST HOUR
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
CPT 96112 GO,CO
|
| Hospital Charge Code |
4596112
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$372.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$235.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$161.55
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$333.20
|
| Rate for Payer: First Health Commercial |
$352.80
|
| Rate for Payer: First Health Workers Compensation |
$151.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$352.80
|
| Rate for Payer: GEHA Commercial |
$313.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$352.80
|
| Rate for Payer: Humana ChoiceCare |
$101.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$164.84
|
| Rate for Payer: Multiplan All |
$356.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$235.20
|
| Rate for Payer: OMNI Networks Commercial |
$274.40
|
| Rate for Payer: One Health Plan PPO/POS |
$352.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$190.33
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$164.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$372.40
|
| Rate for Payer: Three Rivers Provider Network All |
$294.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$344.96
|
| Rate for Payer: United Healthcare Commercial |
$333.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$164.84
|
| Rate for Payer: United Payors & United Providers UP&UP |
$364.56
|
| Rate for Payer: Zelis Auto |
$156.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$196.00
|
| Rate for Payer: Zelis Worker's Compensation |
$107.02
|
|
|
OTA DEVEL TST PHYS/QHP EA ADDL
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 96113 GO,CO
|
| Hospital Charge Code |
4596113
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$153.00
|
| Rate for Payer: First Health Commercial |
$162.00
|
| Rate for Payer: First Health Workers Compensation |
$69.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.00
|
| Rate for Payer: GEHA Commercial |
$144.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.00
|
| Rate for Payer: Humana ChoiceCare |
$46.80
|
| Rate for Payer: Multiplan All |
$163.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$108.00
|
| Rate for Payer: OMNI Networks Commercial |
$126.00
|
| Rate for Payer: One Health Plan PPO/POS |
$162.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.00
|
| Rate for Payer: Three Rivers Provider Network All |
$135.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$158.40
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$167.40
|
| Rate for Payer: Zelis Auto |
$72.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$90.00
|
| Rate for Payer: Zelis Worker's Compensation |
$49.14
|
|
|
OTA DEVEL TST PHYS/QHP EA ADDL
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 96113 GO,CO
|
| Hospital Charge Code |
4596113
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$153.00
|
| Rate for Payer: First Health Commercial |
$162.00
|
| Rate for Payer: First Health Workers Compensation |
$69.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$162.00
|
| Rate for Payer: GEHA Commercial |
$126.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$162.00
|
| Rate for Payer: Multiplan All |
$163.80
|
| Rate for Payer: OMNI Networks Commercial |
$126.00
|
| Rate for Payer: One Health Plan PPO/POS |
$162.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$171.00
|
| Rate for Payer: Three Rivers Provider Network All |
$135.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$167.40
|
| Rate for Payer: Zelis Auto |
$72.00
|
| Rate for Payer: Zelis Worker's Compensation |
$49.14
|
|
|
OTA DIATHERMY EG MICROWAVE
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 97024 GO,CO
|
| Hospital Charge Code |
4597811
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.31 |
| Max. Negotiated Rate |
$126.35 |
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: First Health Commercial |
$119.70
|
| Rate for Payer: First Health Workers Compensation |
$51.35
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$119.70
|
| Rate for Payer: GEHA Commercial |
$93.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$119.70
|
| Rate for Payer: Multiplan All |
$121.03
|
| Rate for Payer: OMNI Networks Commercial |
$93.10
|
| Rate for Payer: One Health Plan PPO/POS |
$119.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$126.35
|
| Rate for Payer: Three Rivers Provider Network All |
$99.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$123.69
|
| Rate for Payer: Zelis Auto |
$53.20
|
| Rate for Payer: Zelis Worker's Compensation |
$36.31
|
|
|
OTA DIATHERMY EG MICROWAVE
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 97024 GO,CO
|
| Hospital Charge Code |
4597811
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$126.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$15.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$15.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$12.13
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: First Health Commercial |
$119.70
|
| Rate for Payer: First Health Workers Compensation |
$13.87
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$119.70
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$119.70
|
| Rate for Payer: Humana ChoiceCare |
$34.58
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$12.38
|
| Rate for Payer: Multiplan All |
$121.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$79.80
|
| Rate for Payer: OMNI Networks Commercial |
$93.10
|
| Rate for Payer: One Health Plan PPO/POS |
$119.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$14.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$12.38
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$126.35
|
| Rate for Payer: Three Rivers Provider Network All |
$99.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$117.04
|
| Rate for Payer: United Healthcare Commercial |
$113.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12.38
|
| Rate for Payer: United Payors & United Providers UP&UP |
$123.69
|
| Rate for Payer: Zelis Auto |
$53.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$66.50
|
| Rate for Payer: Zelis Worker's Compensation |
$9.81
|
|
|
OT ADL TRNG
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
4590184
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$68.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$261.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$68.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$54.51
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$370.60
|
| Rate for Payer: First Health Commercial |
$392.40
|
| Rate for Payer: First Health Workers Compensation |
$61.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$392.40
|
| Rate for Payer: GEHA Commercial |
$348.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$392.40
|
| Rate for Payer: Humana ChoiceCare |
$113.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$55.62
|
| Rate for Payer: Multiplan All |
$396.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$261.60
|
| Rate for Payer: OMNI Networks Commercial |
$305.20
|
| Rate for Payer: One Health Plan PPO/POS |
$392.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$64.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$55.62
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$414.20
|
| Rate for Payer: Three Rivers Provider Network All |
$327.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$383.68
|
| Rate for Payer: United Healthcare Commercial |
$370.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.62
|
| Rate for Payer: United Payors & United Providers UP&UP |
$405.48
|
| Rate for Payer: Zelis Auto |
$174.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$218.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.42
|
|
|
OT ADL TRNG
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
4590184
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$119.03 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$370.60
|
| Rate for Payer: First Health Commercial |
$392.40
|
| Rate for Payer: First Health Workers Compensation |
$168.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$392.40
|
| Rate for Payer: GEHA Commercial |
$305.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$392.40
|
| Rate for Payer: Multiplan All |
$396.76
|
| Rate for Payer: OMNI Networks Commercial |
$305.20
|
| Rate for Payer: One Health Plan PPO/POS |
$392.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$414.20
|
| Rate for Payer: Three Rivers Provider Network All |
$327.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$405.48
|
| Rate for Payer: Zelis Auto |
$174.40
|
| Rate for Payer: Zelis Worker's Compensation |
$119.03
|
|
|
OT ADL TRNG
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
4300037
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$68.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$68.81
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$54.51
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$61.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$153.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Humana ChoiceCare |
$49.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$55.62
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$115.20
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$64.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$55.62
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$168.96
|
| Rate for Payer: United Healthcare Commercial |
$163.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.62
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$96.00
|
| Rate for Payer: Zelis Worker's Compensation |
$43.42
|
|
|
OT ADL TRNG
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
4300037
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$52.42 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: First Health Commercial |
$172.80
|
| Rate for Payer: First Health Workers Compensation |
$74.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$172.80
|
| Rate for Payer: GEHA Commercial |
$134.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$172.80
|
| Rate for Payer: Multiplan All |
$174.72
|
| Rate for Payer: OMNI Networks Commercial |
$134.40
|
| Rate for Payer: One Health Plan PPO/POS |
$172.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$182.40
|
| Rate for Payer: Three Rivers Provider Network All |
$144.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$178.56
|
| Rate for Payer: Zelis Auto |
$76.80
|
| Rate for Payer: Zelis Worker's Compensation |
$52.42
|
|
|
OTA ELEC STIM CONST ATTE
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 97032 GO,CO
|
| Hospital Charge Code |
4597032
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.61 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$30.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$99.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$30.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$24.29
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$141.10
|
| Rate for Payer: First Health Commercial |
$149.40
|
| Rate for Payer: First Health Workers Compensation |
$27.73
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$149.40
|
| Rate for Payer: GEHA Commercial |
$132.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$149.40
|
| Rate for Payer: Humana ChoiceCare |
$43.16
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.78
|
| Rate for Payer: Multiplan All |
$151.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$99.60
|
| Rate for Payer: OMNI Networks Commercial |
$116.20
|
| Rate for Payer: One Health Plan PPO/POS |
$149.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$28.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.78
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$157.70
|
| Rate for Payer: Three Rivers Provider Network All |
$124.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$146.08
|
| Rate for Payer: United Healthcare Commercial |
$141.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.78
|
| Rate for Payer: United Payors & United Providers UP&UP |
$154.38
|
| Rate for Payer: Zelis Auto |
$66.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$83.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.61
|
|
