|
OTA SW TREATMENT
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
CPT 92526 GO,CO
|
| Hospital Charge Code |
4592526
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$92.77 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$117.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$231.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$117.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$92.77
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$327.25
|
| Rate for Payer: First Health Commercial |
$346.50
|
| Rate for Payer: First Health Workers Compensation |
$148.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$346.50
|
| Rate for Payer: GEHA Commercial |
$308.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$346.50
|
| Rate for Payer: Humana ChoiceCare |
$100.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$94.66
|
| Rate for Payer: Multiplan All |
$350.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$231.00
|
| Rate for Payer: OMNI Networks Commercial |
$269.50
|
| Rate for Payer: One Health Plan PPO/POS |
$346.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$109.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$94.66
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$365.75
|
| Rate for Payer: Three Rivers Provider Network All |
$288.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$338.80
|
| Rate for Payer: United Healthcare Commercial |
$327.25
|
| Rate for Payer: United Healthcare Managed Medicaid |
$94.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.05
|
| Rate for Payer: Zelis Auto |
$154.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$192.50
|
| Rate for Payer: Zelis Worker's Compensation |
$105.11
|
|
|
OTA SW TREATMENT
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
CPT 92526 GO,CO
|
| Hospital Charge Code |
4592526
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$105.11 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$327.25
|
| Rate for Payer: First Health Commercial |
$346.50
|
| Rate for Payer: First Health Workers Compensation |
$148.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$346.50
|
| Rate for Payer: GEHA Commercial |
$269.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$346.50
|
| Rate for Payer: Multiplan All |
$350.35
|
| Rate for Payer: OMNI Networks Commercial |
$269.50
|
| Rate for Payer: One Health Plan PPO/POS |
$346.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$365.75
|
| Rate for Payer: Three Rivers Provider Network All |
$288.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.05
|
| Rate for Payer: Zelis Auto |
$154.00
|
| Rate for Payer: Zelis Worker's Compensation |
$105.11
|
|
|
OTA THERAPEUTIC ACTIVITES
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 97530 GO,CO
|
| Hospital Charge Code |
4597530
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$42.44
|
| 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 |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$33.62
|
| 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 |
$68.68
|
| 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 |
$34.30
|
| 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 |
$39.61
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$34.30
|
| 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 |
$34.30
|
| 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 |
$48.56
|
|
|
OTA THERAPEUTIC ACTIVITES
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 97530 GO,CO
|
| Hospital Charge Code |
4597530
|
|
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 THERAP GROUP 2 OR MO
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
CPT 97150 GO,CO
|
| Hospital Charge Code |
4597150
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$24.28 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$124.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.33
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$34.33
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$166.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Humana ChoiceCare |
$54.08
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$30.94
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.80
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$30.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$183.04
|
| Rate for Payer: United Healthcare Commercial |
$176.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$30.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$104.00
|
| Rate for Payer: Zelis Worker's Compensation |
$24.28
|
|
|
OTA THERAP GROUP 2 OR MO
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
CPT 97150 GO,CO
|
| Hospital Charge Code |
4597150
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.78 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$176.80
|
| Rate for Payer: First Health Commercial |
$187.20
|
| Rate for Payer: First Health Workers Compensation |
$80.31
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$187.20
|
| Rate for Payer: GEHA Commercial |
$145.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$187.20
|
| Rate for Payer: Multiplan All |
$189.28
|
| Rate for Payer: OMNI Networks Commercial |
$145.60
|
| Rate for Payer: One Health Plan PPO/POS |
$187.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$197.60
|
| Rate for Payer: Three Rivers Provider Network All |
$156.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$193.44
|
| Rate for Payer: Zelis Auto |
$83.20
|
| Rate for Payer: Zelis Worker's Compensation |
$56.78
|
|
|
OTA THERAPTC MASSGE E15M
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
4597124
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$57.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$105.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Worker's Compensation |
$40.95
|
|
|
OTA THERAPTC MASSGE E15M
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
4597124
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$63.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$90.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$63.45
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.27
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$127.50
|
| Rate for Payer: First Health Commercial |
$135.00
|
| Rate for Payer: First Health Workers Compensation |
$56.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$135.00
|
| Rate for Payer: GEHA Commercial |
$120.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$135.00
|
| Rate for Payer: Humana ChoiceCare |
$39.00
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.29
|
| Rate for Payer: Multiplan All |
$136.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$90.00
|
| Rate for Payer: OMNI Networks Commercial |
$105.00
|
| Rate for Payer: One Health Plan PPO/POS |
$135.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$59.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$142.50
|
| Rate for Payer: Three Rivers Provider Network All |
$112.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$132.00
|
| Rate for Payer: United Healthcare Commercial |
$127.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$139.50
|
| Rate for Payer: Zelis Auto |
$60.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$75.00
|
| Rate for Payer: Zelis Worker's Compensation |
$40.15
|
|
|
OTA THER EX E15
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT 97110 GO,CO
|
| Hospital Charge Code |
4597110
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.32 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$150.45
|
| Rate for Payer: First Health Commercial |
$159.30
|
| Rate for Payer: First Health Workers Compensation |
$68.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$159.30
|
| Rate for Payer: GEHA Commercial |
$123.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$159.30
|
| Rate for Payer: Multiplan All |
$161.07
|
| Rate for Payer: OMNI Networks Commercial |
$123.90
|
| Rate for Payer: One Health Plan PPO/POS |
$159.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$168.15
|
| Rate for Payer: Three Rivers Provider Network All |
$132.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$164.61
|
| Rate for Payer: Zelis Auto |
$70.80
|
| Rate for Payer: Zelis Worker's Compensation |
$48.32
|
|
|
OTA THER EX E15
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT 97110 GO,CO
|
| Hospital Charge Code |
4597110
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$39.22 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$62.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$106.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$62.12
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$49.21
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$150.45
|
| Rate for Payer: First Health Commercial |
$159.30
|
| Rate for Payer: First Health Workers Compensation |
$55.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$159.30
|
| Rate for Payer: GEHA Commercial |
$141.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$159.30
|
| Rate for Payer: Humana ChoiceCare |
$46.02
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$50.21
|
| Rate for Payer: Multiplan All |
$161.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$106.20
|
| Rate for Payer: OMNI Networks Commercial |
$123.90
|
| Rate for Payer: One Health Plan PPO/POS |
$159.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$57.97
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$50.21
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$168.15
|
| Rate for Payer: Three Rivers Provider Network All |
$132.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$155.76
|
| Rate for Payer: United Healthcare Commercial |
$150.45
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.21
|
| Rate for Payer: United Payors & United Providers UP&UP |
$164.61
|
| Rate for Payer: Zelis Auto |
$70.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$88.50
|
| Rate for Payer: Zelis Worker's Compensation |
$39.22
|
|
|
OTA THER INVTJ W/FOCUS COG FUNCJ
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 97127 GO,CO
|
| Hospital Charge Code |
4597127
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$114.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
OTA THER INVTJ W/FOCUS COG FUNCJ
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 97127 GO,CO
|
| Hospital Charge Code |
4597127
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.75 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$138.55
|
| Rate for Payer: First Health Commercial |
$146.70
|
| Rate for Payer: First Health Workers Compensation |
$62.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$146.70
|
| Rate for Payer: GEHA Commercial |
$130.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$146.70
|
| Rate for Payer: Humana ChoiceCare |
$42.38
|
| Rate for Payer: Multiplan All |
$148.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$97.80
|
| Rate for Payer: OMNI Networks Commercial |
$114.10
|
| Rate for Payer: One Health Plan PPO/POS |
$146.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$154.85
|
| Rate for Payer: Three Rivers Provider Network All |
$122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$143.44
|
| Rate for Payer: United Healthcare Commercial |
$138.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$40.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$151.59
|
| Rate for Payer: Zelis Auto |
$65.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.50
|
| Rate for Payer: Zelis Worker's Compensation |
$44.50
|
|
|
OTA THER IVNT COG FUN CNTCT EA ADL 15 MI
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 97130 GO,CO
|
| Hospital Charge Code |
4597130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$46.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$42.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$46.26
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.65
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$59.50
|
| Rate for Payer: First Health Commercial |
$63.00
|
| Rate for Payer: First Health Workers Compensation |
$41.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.00
|
| Rate for Payer: GEHA Commercial |
$56.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.00
|
| Rate for Payer: Humana ChoiceCare |
$18.20
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$37.39
|
| Rate for Payer: Multiplan All |
$63.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$42.00
|
| Rate for Payer: OMNI Networks Commercial |
$49.00
|
| Rate for Payer: One Health Plan PPO/POS |
$63.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$43.18
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$37.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$66.50
|
| Rate for Payer: Three Rivers Provider Network All |
$52.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$61.60
|
| Rate for Payer: United Healthcare Commercial |
$59.50
|
| Rate for Payer: United Healthcare Managed Medicaid |
$37.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$65.10
|
| Rate for Payer: Zelis Auto |
$28.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$35.00
|
| Rate for Payer: Zelis Worker's Compensation |
$29.41
|
|
|
OTA THER IVNT COG FUN CNTCT EA ADL 15 MI
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 97130 GO,CO
|
| Hospital Charge Code |
4597130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.11 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$59.50
|
| Rate for Payer: First Health Commercial |
$63.00
|
| Rate for Payer: First Health Workers Compensation |
$27.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$63.00
|
| Rate for Payer: GEHA Commercial |
$49.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$63.00
|
| Rate for Payer: Multiplan All |
$63.70
|
| Rate for Payer: OMNI Networks Commercial |
$49.00
|
| Rate for Payer: One Health Plan PPO/POS |
$63.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$66.50
|
| Rate for Payer: Three Rivers Provider Network All |
$52.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$65.10
|
| Rate for Payer: Zelis Auto |
$28.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.11
|
|
|
OTA THER IVNTJ COG FUNC CNTCT 1ST 15 MIN
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 97129 GO,CO
|
| Hospital Charge Code |
4597129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$48.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$48.41
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$38.35
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$43.58
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$57.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Humana ChoiceCare |
$18.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$39.13
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$43.20
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$45.18
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$39.13
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$63.36
|
| Rate for Payer: United Healthcare Commercial |
$61.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$39.13
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$36.00
|
| Rate for Payer: Zelis Worker's Compensation |
$30.81
|
|
|
OTA THER IVNTJ COG FUNC CNTCT 1ST 15 MIN
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 97129 GO,CO
|
| Hospital Charge Code |
4597129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: First Health Commercial |
$64.80
|
| Rate for Payer: First Health Workers Compensation |
$27.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$64.80
|
| Rate for Payer: GEHA Commercial |
$50.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$64.80
|
| Rate for Payer: Multiplan All |
$65.52
|
| Rate for Payer: OMNI Networks Commercial |
$50.40
|
| Rate for Payer: One Health Plan PPO/POS |
$64.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$68.40
|
| Rate for Payer: Three Rivers Provider Network All |
$54.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$66.96
|
| Rate for Payer: Zelis Auto |
$28.80
|
| Rate for Payer: Zelis Worker's Compensation |
$19.66
|
|
|
OTA ULTRAVIOLET THERAPY
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 97028 GO,CO
|
| Hospital Charge Code |
4597813
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$47.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$86.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Worker's Compensation |
$33.58
|
|
|
OTA ULTRAVIOLET THERAPY
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 97028 GO,CO
|
| Hospital Charge Code |
4597813
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$17.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$17.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.83
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$104.55
|
| Rate for Payer: First Health Commercial |
$110.70
|
| Rate for Payer: First Health Workers Compensation |
$15.85
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$110.70
|
| Rate for Payer: GEHA Commercial |
$98.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$110.70
|
| Rate for Payer: Humana ChoiceCare |
$31.98
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$14.11
|
| Rate for Payer: Multiplan All |
$111.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$73.80
|
| Rate for Payer: OMNI Networks Commercial |
$86.10
|
| Rate for Payer: One Health Plan PPO/POS |
$110.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$16.30
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$14.11
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$116.85
|
| Rate for Payer: Three Rivers Provider Network All |
$92.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$108.24
|
| Rate for Payer: United Healthcare Commercial |
$104.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14.11
|
| Rate for Payer: United Payors & United Providers UP&UP |
$114.39
|
| Rate for Payer: Zelis Auto |
$49.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$61.50
|
| Rate for Payer: Zelis Worker's Compensation |
$11.21
|
|
|
OTA UNLISTED MODALITY, CONSTANT ATTEND
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 97039 GO,CO
|
| Hospital Charge Code |
4597039
|
|
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 UNLISTED MODALITY, CONSTANT ATTEND
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 97039 GO,CO
|
| Hospital Charge Code |
4597039
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.52 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$22.11
|
| 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 |
$22.11
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$17.52
|
| 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: 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 |
$17.87
|
| 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 |
$20.64
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$17.87
|
| 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 |
$17.87
|
| 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
|
|
|
OTA UNLISTED PHYSICAL MEDICINE/REHABILIT
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 97799 GO,CO
|
| Hospital Charge Code |
4597820
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$302.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$190.80
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$270.30
|
| Rate for Payer: First Health Commercial |
$286.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$286.20
|
| Rate for Payer: GEHA Commercial |
$254.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$286.20
|
| Rate for Payer: Humana ChoiceCare |
$82.68
|
| Rate for Payer: Multiplan All |
$289.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$190.80
|
| Rate for Payer: OMNI Networks Commercial |
$222.60
|
| Rate for Payer: One Health Plan PPO/POS |
$286.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$302.10
|
| Rate for Payer: Three Rivers Provider Network All |
$238.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$279.84
|
| Rate for Payer: United Healthcare Commercial |
$270.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$295.74
|
| Rate for Payer: Zelis Auto |
$127.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$159.00
|
|
|
OTA UNLISTED PHYSICAL MEDICINE/REHABILIT
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT 97799 GO,CO
|
| Hospital Charge Code |
4597820
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$86.81 |
| Max. Negotiated Rate |
$302.10 |
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$270.30
|
| Rate for Payer: First Health Commercial |
$286.20
|
| Rate for Payer: First Health Workers Compensation |
$122.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$286.20
|
| Rate for Payer: GEHA Commercial |
$222.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$286.20
|
| Rate for Payer: Multiplan All |
$289.38
|
| Rate for Payer: OMNI Networks Commercial |
$222.60
|
| Rate for Payer: One Health Plan PPO/POS |
$286.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$302.10
|
| Rate for Payer: Three Rivers Provider Network All |
$238.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$295.74
|
| Rate for Payer: Zelis Auto |
$127.20
|
| Rate for Payer: Zelis Worker's Compensation |
$86.81
|
|
|
OTA UNLISTED THERAPEUTIC PROCEDURE (SPEC
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 97139 GO,CO
|
| Hospital Charge Code |
4597816
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$39.04 |
| Max. Negotiated Rate |
$135.85 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$121.55
|
| Rate for Payer: First Health Commercial |
$128.70
|
| Rate for Payer: First Health Workers Compensation |
$55.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$128.70
|
| Rate for Payer: GEHA Commercial |
$100.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$128.70
|
| Rate for Payer: Multiplan All |
$130.13
|
| Rate for Payer: OMNI Networks Commercial |
$100.10
|
| Rate for Payer: One Health Plan PPO/POS |
$128.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$135.85
|
| Rate for Payer: Three Rivers Provider Network All |
$107.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$132.99
|
| Rate for Payer: Zelis Auto |
$57.20
|
| Rate for Payer: Zelis Worker's Compensation |
$39.04
|
|
|
OTA UNLISTED THERAPEUTIC PROCEDURE (SPEC
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 97139 GO,CO
|
| Hospital Charge Code |
4597816
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$21.16 |
| Max. Negotiated Rate |
$135.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$26.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$85.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$26.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$21.16
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$121.55
|
| Rate for Payer: First Health Commercial |
$128.70
|
| Rate for Payer: First Health Workers Compensation |
$55.21
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$128.70
|
| Rate for Payer: GEHA Commercial |
$114.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$128.70
|
| Rate for Payer: Humana ChoiceCare |
$37.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$21.59
|
| Rate for Payer: Multiplan All |
$130.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$85.80
|
| Rate for Payer: OMNI Networks Commercial |
$100.10
|
| Rate for Payer: One Health Plan PPO/POS |
$128.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$24.93
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$21.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$135.85
|
| Rate for Payer: Three Rivers Provider Network All |
$107.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$125.84
|
| Rate for Payer: United Healthcare Commercial |
$121.55
|
| Rate for Payer: United Healthcare Managed Medicaid |
$21.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$132.99
|
| Rate for Payer: Zelis Auto |
$57.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$71.50
|
| Rate for Payer: Zelis Worker's Compensation |
$39.04
|
|
|
OTA US-15 MIN
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 97035 GO,CO
|
| Hospital Charge Code |
4597035
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna Commercial |
$108.80
|
| Rate for Payer: First Health Commercial |
$115.20
|
| Rate for Payer: First Health Workers Compensation |
$49.42
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$115.20
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$115.20
|
| Rate for Payer: Multiplan All |
$116.48
|
| Rate for Payer: OMNI Networks Commercial |
$89.60
|
| Rate for Payer: One Health Plan PPO/POS |
$115.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$121.60
|
| Rate for Payer: Three Rivers Provider Network All |
$96.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.04
|
| Rate for Payer: Zelis Auto |
$51.20
|
| Rate for Payer: Zelis Worker's Compensation |
$34.94
|
|
