|
OTA HLTH BHVIOR IVNT FM W/PT F2F EA AD15
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
CPT 96168 GO,CO
|
| Hospital Charge Code |
4500019
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$67.45 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$60.35
|
| Rate for Payer: First Health Commercial |
$63.90
|
| Rate for Payer: First Health Workers Compensation |
$27.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.90
|
| Rate for Payer: GEHA Commercial |
$49.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.90
|
| Rate for Payer: Multiplan All |
$64.61
|
| Rate for Payer: OMNI Networks Commercial |
$49.70
|
| Rate for Payer: One Health Plan PPO/POS |
$63.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$67.45
|
| Rate for Payer: Three Rivers Provider Network All |
$53.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.03
|
| Rate for Payer: Zelis Auto |
$28.40
|
| Rate for Payer: Zelis Worker's Compensation |
$19.38
|
|
|
OTA HLTH BHVIOR IVNT FM W/PT F2F EA AD15
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
CPT 96168 GO,CO
|
| Hospital Charge Code |
4500019
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$17.75 |
| Max. Negotiated Rate |
$67.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$60.35
|
| Rate for Payer: First Health Commercial |
$63.90
|
| Rate for Payer: First Health Workers Compensation |
$27.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.90
|
| Rate for Payer: GEHA Commercial |
$56.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.90
|
| Rate for Payer: Humana ChoiceCare |
$18.46
|
| Rate for Payer: Multiplan All |
$64.61
|
| Rate for Payer: New Mexico Health Connections Medicare |
$42.60
|
| Rate for Payer: OMNI Networks Commercial |
$49.70
|
| Rate for Payer: One Health Plan PPO/POS |
$63.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$67.45
|
| Rate for Payer: Three Rivers Provider Network All |
$53.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$62.48
|
| Rate for Payer: United Healthcare Commercial |
$60.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.03
|
| Rate for Payer: Zelis Auto |
$28.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.38
|
|
|
OTA HYDROTHERAPY, CONSTANT ATTENDANCE
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 97036 GO,CO
|
| Hospital Charge Code |
4597814
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$72.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$166.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$72.33
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$57.30
|
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cigna Commercial |
$235.45
|
| Rate for Payer: First Health Commercial |
$249.30
|
| Rate for Payer: First Health Workers Compensation |
$64.72
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$249.30
|
| Rate for Payer: GEHA Commercial |
$221.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$249.30
|
| Rate for Payer: Humana ChoiceCare |
$72.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$58.47
|
| Rate for Payer: Multiplan All |
$252.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$166.20
|
| Rate for Payer: OMNI Networks Commercial |
$193.90
|
| Rate for Payer: One Health Plan PPO/POS |
$249.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$67.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$58.47
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$263.15
|
| Rate for Payer: Three Rivers Provider Network All |
$207.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$243.76
|
| Rate for Payer: United Healthcare Commercial |
$235.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$58.47
|
| Rate for Payer: United Payors & United Providers UP&UP |
$257.61
|
| Rate for Payer: Zelis Auto |
$110.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$138.50
|
| Rate for Payer: Zelis Worker's Compensation |
$45.76
|
|
|
OTA HYDROTHERAPY, CONSTANT ATTENDANCE
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 97036 GO,CO
|
| Hospital Charge Code |
4597814
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$75.62 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Cash Price |
$166.20
|
| Rate for Payer: Cigna Commercial |
$235.45
|
| Rate for Payer: First Health Commercial |
$249.30
|
| Rate for Payer: First Health Workers Compensation |
$106.95
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$249.30
|
| Rate for Payer: GEHA Commercial |
$193.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$249.30
|
| Rate for Payer: Multiplan All |
$252.07
|
| Rate for Payer: OMNI Networks Commercial |
$193.90
|
| Rate for Payer: One Health Plan PPO/POS |
$249.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$263.15
|
| Rate for Payer: Three Rivers Provider Network All |
$207.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$257.61
|
| Rate for Payer: Zelis Auto |
$110.80
|
| Rate for Payer: Zelis Worker's Compensation |
$75.62
|
|
|
OTA INFRARED THERAPY
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 97026 GO,CO
|
| Hospital Charge Code |
4597812
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$11.07
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$12.54
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$96.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Humana ChoiceCare |
$31.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$11.30
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$72.00
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$13.05
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$11.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$105.60
|
| Rate for Payer: United Healthcare Commercial |
$102.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.30
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$60.00
|
| Rate for Payer: Zelis Worker's Compensation |
$8.87
|
|
|
OTA INFRARED THERAPY
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 97026 GO,CO
|
| Hospital Charge Code |
4597812
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$102.00
|
| Rate for Payer: First Health Commercial |
$108.00
|
| Rate for Payer: First Health Workers Compensation |
$46.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$108.00
|
| Rate for Payer: GEHA Commercial |
$84.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$108.00
|
| Rate for Payer: Multiplan All |
$109.20
|
| Rate for Payer: OMNI Networks Commercial |
$84.00
|
| Rate for Payer: One Health Plan PPO/POS |
$108.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$114.00
|
| Rate for Payer: Three Rivers Provider Network All |
$90.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$111.60
|
| Rate for Payer: Zelis Auto |
$48.00
|
| Rate for Payer: Zelis Worker's Compensation |
$32.76
|
|
|
OTA IONTOPHORESIS
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
4597033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$58.69
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$106.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Worker's Compensation |
$41.50
|
|
|
OTA IONTOPHORESIS
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
4597033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$25.68 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$40.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$32.29
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: First Health Workers Compensation |
$36.32
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$136.80
|
| Rate for Payer: GEHA Commercial |
$121.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$136.80
|
| Rate for Payer: Humana ChoiceCare |
$39.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$32.94
|
| Rate for Payer: Multiplan All |
$138.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$91.20
|
| Rate for Payer: OMNI Networks Commercial |
$106.40
|
| Rate for Payer: One Health Plan PPO/POS |
$136.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$38.04
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$32.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$144.40
|
| Rate for Payer: Three Rivers Provider Network All |
$114.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$133.76
|
| Rate for Payer: United Healthcare Commercial |
$129.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$32.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$141.36
|
| Rate for Payer: Zelis Auto |
$60.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$76.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.68
|
|
|
OTA LOW FREQ NON THERMAL US
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
CPT 97610 GO,CO
|
| Hospital Charge Code |
4597818
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$92.30 |
| Max. Negotiated Rate |
$771.92 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$116.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$234.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$116.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$92.30
|
| Rate for Payer: Cash Price |
$234.60
|
| Rate for Payer: Cash Price |
$234.60
|
| Rate for Payer: Cigna Commercial |
$332.35
|
| Rate for Payer: First Health Commercial |
$351.90
|
| Rate for Payer: First Health Workers Compensation |
$771.92
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$351.90
|
| Rate for Payer: GEHA Commercial |
$312.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$351.90
|
| Rate for Payer: Humana ChoiceCare |
$101.66
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$94.17
|
| Rate for Payer: Multiplan All |
$355.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$234.60
|
| Rate for Payer: OMNI Networks Commercial |
$273.70
|
| Rate for Payer: One Health Plan PPO/POS |
$351.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$108.74
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$94.17
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$371.45
|
| Rate for Payer: Three Rivers Provider Network All |
$293.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$344.08
|
| Rate for Payer: United Healthcare Commercial |
$332.35
|
| Rate for Payer: United Healthcare Managed Medicaid |
$94.17
|
| Rate for Payer: United Payors & United Providers UP&UP |
$363.63
|
| Rate for Payer: Zelis Auto |
$156.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$195.50
|
| Rate for Payer: Zelis Worker's Compensation |
$545.80
|
|
|
OTA LOW FREQ NON THERMAL US
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
CPT 97610 GO,CO
|
| Hospital Charge Code |
4597818
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$371.45 |
| Rate for Payer: Cash Price |
$234.60
|
| Rate for Payer: Cigna Commercial |
$332.35
|
| Rate for Payer: First Health Commercial |
$351.90
|
| Rate for Payer: First Health Workers Compensation |
$150.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$351.90
|
| Rate for Payer: GEHA Commercial |
$273.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$351.90
|
| Rate for Payer: Multiplan All |
$355.81
|
| Rate for Payer: OMNI Networks Commercial |
$273.70
|
| Rate for Payer: One Health Plan PPO/POS |
$351.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$371.45
|
| Rate for Payer: Three Rivers Provider Network All |
$293.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$363.63
|
| Rate for Payer: Zelis Auto |
$156.40
|
| Rate for Payer: Zelis Worker's Compensation |
$106.74
|
|
|
OTA MANUAL THERAPY
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 97140 GO,CO
|
| Hospital Charge Code |
4597140
|
|
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
|
|
|
OTA MANUAL THERAPY
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 97140 GO,CO
|
| Hospital Charge Code |
4597140
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.42 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$57.30
|
| 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 |
$57.30
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$45.39
|
| 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 |
$51.51
|
| 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 |
$46.32
|
| 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 |
$53.48
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$46.32
|
| 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 |
$46.32
|
| 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 |
$36.42
|
|
|
OTA MECHANICAL TRACTION
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 97012 GO,CO
|
| Hospital Charge Code |
4597012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
OTA MECHANICAL TRACTION
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 97012 GO,CO
|
| Hospital Charge Code |
4597012
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$21.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$21.66
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.16
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$27.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$35.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$17.51
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$82.20
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$20.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$120.56
|
| Rate for Payer: United Healthcare Commercial |
$116.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$17.51
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.50
|
| Rate for Payer: Zelis Worker's Compensation |
$19.14
|
|
|
OTA MOTION FLUOROSCOPY/SWALLOW MBS
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 92611 GO,CO
|
| Hospital Charge Code |
4592611
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$101.53 |
| Max. Negotiated Rate |
$592.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$128.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$374.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$128.16
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$101.53
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$530.40
|
| Rate for Payer: First Health Commercial |
$561.60
|
| Rate for Payer: First Health Workers Compensation |
$240.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$561.60
|
| Rate for Payer: GEHA Commercial |
$499.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$561.60
|
| Rate for Payer: Humana ChoiceCare |
$162.24
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$103.60
|
| Rate for Payer: Multiplan All |
$567.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$374.40
|
| Rate for Payer: OMNI Networks Commercial |
$436.80
|
| Rate for Payer: One Health Plan PPO/POS |
$561.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$119.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$103.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$592.80
|
| Rate for Payer: Three Rivers Provider Network All |
$468.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$549.12
|
| Rate for Payer: United Healthcare Commercial |
$530.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$103.60
|
| Rate for Payer: United Payors & United Providers UP&UP |
$580.32
|
| Rate for Payer: Zelis Auto |
$249.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$312.00
|
| Rate for Payer: Zelis Worker's Compensation |
$170.35
|
|
|
OTA MOTION FLUOROSCOPY/SWALLOW MBS
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT 92611 GO,CO
|
| Hospital Charge Code |
4592611
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$170.35 |
| Max. Negotiated Rate |
$592.80 |
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$530.40
|
| Rate for Payer: First Health Commercial |
$561.60
|
| Rate for Payer: First Health Workers Compensation |
$240.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$561.60
|
| Rate for Payer: GEHA Commercial |
$436.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$561.60
|
| Rate for Payer: Multiplan All |
$567.84
|
| Rate for Payer: OMNI Networks Commercial |
$436.80
|
| Rate for Payer: One Health Plan PPO/POS |
$561.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$592.80
|
| Rate for Payer: Three Rivers Provider Network All |
$468.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$580.32
|
| Rate for Payer: Zelis Auto |
$249.60
|
| Rate for Payer: Zelis Worker's Compensation |
$170.35
|
|
|
OTA MUSCLE TESTING, EXTREMITY OR TRUNK
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 95831 GO,CO
|
| Hospital Charge Code |
4597802
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: First Health Workers Compensation |
$88.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$205.20
|
| Rate for Payer: GEHA Commercial |
$182.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$205.20
|
| Rate for Payer: Humana ChoiceCare |
$59.28
|
| Rate for Payer: Multiplan All |
$207.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$136.80
|
| Rate for Payer: OMNI Networks Commercial |
$159.60
|
| Rate for Payer: One Health Plan PPO/POS |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$216.60
|
| Rate for Payer: Three Rivers Provider Network All |
$171.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$200.64
|
| Rate for Payer: United Healthcare Commercial |
$193.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.04
|
| Rate for Payer: Zelis Auto |
$91.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$114.00
|
| Rate for Payer: Zelis Worker's Compensation |
$62.24
|
|
|
OTA MUSCLE TESTING, EXTREMITY OR TRUNK
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 95831 GO,CO
|
| Hospital Charge Code |
4597802
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.24 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$193.80
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: First Health Workers Compensation |
$88.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$205.20
|
| Rate for Payer: GEHA Commercial |
$159.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$205.20
|
| Rate for Payer: Multiplan All |
$207.48
|
| Rate for Payer: OMNI Networks Commercial |
$159.60
|
| Rate for Payer: One Health Plan PPO/POS |
$205.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$216.60
|
| Rate for Payer: Three Rivers Provider Network All |
$171.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$212.04
|
| Rate for Payer: Zelis Auto |
$91.20
|
| Rate for Payer: Zelis Worker's Compensation |
$62.24
|
|
|
OTA MUSCLE TESTING/HAND
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
CPT 95832 GO,CO
|
| Hospital Charge Code |
4597803
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.04 |
| Max. Negotiated Rate |
$125.40 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$112.20
|
| Rate for Payer: First Health Commercial |
$118.80
|
| Rate for Payer: First Health Workers Compensation |
$50.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$118.80
|
| Rate for Payer: GEHA Commercial |
$92.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$118.80
|
| Rate for Payer: Multiplan All |
$120.12
|
| Rate for Payer: OMNI Networks Commercial |
$92.40
|
| Rate for Payer: One Health Plan PPO/POS |
$118.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$125.40
|
| Rate for Payer: Three Rivers Provider Network All |
$99.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$122.76
|
| Rate for Payer: Zelis Auto |
$52.80
|
| Rate for Payer: Zelis Worker's Compensation |
$36.04
|
|
|
OTA MUSCLE TESTING/HAND
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
CPT 95832 GO,CO
|
| Hospital Charge Code |
4597803
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$125.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$112.20
|
| Rate for Payer: First Health Commercial |
$118.80
|
| Rate for Payer: First Health Workers Compensation |
$50.97
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$118.80
|
| Rate for Payer: GEHA Commercial |
$105.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$118.80
|
| Rate for Payer: Humana ChoiceCare |
$34.32
|
| Rate for Payer: Multiplan All |
$120.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$79.20
|
| Rate for Payer: OMNI Networks Commercial |
$92.40
|
| Rate for Payer: One Health Plan PPO/POS |
$118.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$125.40
|
| Rate for Payer: Three Rivers Provider Network All |
$99.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$116.16
|
| Rate for Payer: United Healthcare Commercial |
$112.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$33.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$122.76
|
| Rate for Payer: Zelis Auto |
$52.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$66.00
|
| Rate for Payer: Zelis Worker's Compensation |
$36.04
|
|
|
OTA MUSCLE TESTNG, TOTAL EVALUATION OF B
|
Facility
|
IP
|
$518.00
|
|
|
Service Code
|
CPT 95833 GO,CO
|
| Hospital Charge Code |
4597804
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$141.41 |
| Max. Negotiated Rate |
$492.10 |
| Rate for Payer: Cash Price |
$310.80
|
| Rate for Payer: Cigna Commercial |
$440.30
|
| Rate for Payer: First Health Commercial |
$466.20
|
| Rate for Payer: First Health Workers Compensation |
$200.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$466.20
|
| Rate for Payer: GEHA Commercial |
$362.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$466.20
|
| Rate for Payer: Multiplan All |
$471.38
|
| Rate for Payer: OMNI Networks Commercial |
$362.60
|
| Rate for Payer: One Health Plan PPO/POS |
$466.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$492.10
|
| Rate for Payer: Three Rivers Provider Network All |
$388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$481.74
|
| Rate for Payer: Zelis Auto |
$207.20
|
| Rate for Payer: Zelis Worker's Compensation |
$141.41
|
|
|
OTA MUSCLE TESTNG, TOTAL EVALUATION OF B
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
CPT 95834 GO,CO
|
| Hospital Charge Code |
4597805
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$96.64 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$300.90
|
| Rate for Payer: First Health Commercial |
$318.60
|
| Rate for Payer: First Health Workers Compensation |
$136.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$318.60
|
| Rate for Payer: GEHA Commercial |
$247.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$318.60
|
| Rate for Payer: Multiplan All |
$322.14
|
| Rate for Payer: OMNI Networks Commercial |
$247.80
|
| Rate for Payer: One Health Plan PPO/POS |
$318.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$336.30
|
| Rate for Payer: Three Rivers Provider Network All |
$265.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$329.22
|
| Rate for Payer: Zelis Auto |
$141.60
|
| Rate for Payer: Zelis Worker's Compensation |
$96.64
|
|
|
OTA MUSCLE TESTNG, TOTAL EVALUATION OF B
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
CPT 95834 GO,CO
|
| Hospital Charge Code |
4597805
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$212.40
|
| Rate for Payer: Cash Price |
$212.40
|
| Rate for Payer: Cigna Commercial |
$300.90
|
| Rate for Payer: First Health Commercial |
$318.60
|
| Rate for Payer: First Health Workers Compensation |
$136.68
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$318.60
|
| Rate for Payer: GEHA Commercial |
$283.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$318.60
|
| Rate for Payer: Humana ChoiceCare |
$92.04
|
| Rate for Payer: Multiplan All |
$322.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$212.40
|
| Rate for Payer: OMNI Networks Commercial |
$247.80
|
| Rate for Payer: One Health Plan PPO/POS |
$318.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$336.30
|
| Rate for Payer: Three Rivers Provider Network All |
$265.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$311.52
|
| Rate for Payer: United Healthcare Commercial |
$300.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$88.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$329.22
|
| Rate for Payer: Zelis Auto |
$141.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$177.00
|
| Rate for Payer: Zelis Worker's Compensation |
$96.64
|
|
|
OTA MUSCLE TESTNG, TOTAL EVALUATION OF B
|
Facility
|
OP
|
$518.00
|
|
|
Service Code
|
CPT 95833 GO,CO
|
| Hospital Charge Code |
4597804
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$492.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$310.80
|
| Rate for Payer: Cash Price |
$310.80
|
| Rate for Payer: Cigna Commercial |
$440.30
|
| Rate for Payer: First Health Commercial |
$466.20
|
| Rate for Payer: First Health Workers Compensation |
$200.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$466.20
|
| Rate for Payer: GEHA Commercial |
$414.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$466.20
|
| Rate for Payer: Humana ChoiceCare |
$134.68
|
| Rate for Payer: Multiplan All |
$471.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$310.80
|
| Rate for Payer: OMNI Networks Commercial |
$362.60
|
| Rate for Payer: One Health Plan PPO/POS |
$466.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$492.10
|
| Rate for Payer: Three Rivers Provider Network All |
$388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$455.84
|
| Rate for Payer: United Healthcare Commercial |
$440.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$481.74
|
| Rate for Payer: Zelis Auto |
$207.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$259.00
|
| Rate for Payer: Zelis Worker's Compensation |
$141.41
|
|
|
OT AND PT SERVICES CLINIC
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
4390129
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$18.70
|
| Rate for Payer: First Health Commercial |
$19.80
|
| Rate for Payer: First Health Workers Compensation |
$8.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19.80
|
| Rate for Payer: GEHA Commercial |
$15.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19.80
|
| Rate for Payer: Multiplan All |
$20.02
|
| Rate for Payer: OMNI Networks Commercial |
$15.40
|
| Rate for Payer: One Health Plan PPO/POS |
$19.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20.90
|
| Rate for Payer: Three Rivers Provider Network All |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$20.46
|
| Rate for Payer: Zelis Auto |
$8.80
|
| Rate for Payer: Zelis Worker's Compensation |
$6.01
|
|
