|
OT HLTH BHAVIOR IVNTJ GRP F2F EA AD 15M
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT 96165
|
| Hospital Charge Code |
4500014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$10.20
|
| Rate for Payer: First Health Commercial |
$10.80
|
| Rate for Payer: First Health Workers Compensation |
$4.63
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10.80
|
| Rate for Payer: GEHA Commercial |
$8.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10.80
|
| Rate for Payer: Multiplan All |
$10.92
|
| Rate for Payer: OMNI Networks Commercial |
$8.40
|
| Rate for Payer: One Health Plan PPO/POS |
$10.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11.40
|
| Rate for Payer: Three Rivers Provider Network All |
$9.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11.16
|
| Rate for Payer: Zelis Auto |
$4.80
|
| Rate for Payer: Zelis Worker's Compensation |
$3.28
|
|
|
OT HLTH BHVIOR IVNT FAM W/PT F2F 1ST 30M
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 96167
|
| Hospital Charge Code |
4500016
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$170.00
|
| Rate for Payer: First Health Commercial |
$180.00
|
| Rate for Payer: First Health Workers Compensation |
$77.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$180.00
|
| Rate for Payer: GEHA Commercial |
$140.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$180.00
|
| Rate for Payer: Multiplan All |
$182.00
|
| Rate for Payer: OMNI Networks Commercial |
$140.00
|
| Rate for Payer: One Health Plan PPO/POS |
$180.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$190.00
|
| Rate for Payer: Three Rivers Provider Network All |
$150.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$186.00
|
| Rate for Payer: Zelis Auto |
$80.00
|
| Rate for Payer: Zelis Worker's Compensation |
$54.60
|
|
|
OT HLTH BHVIOR IVNT FAM W/PT F2F 1ST 30M
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT 96167
|
| Hospital Charge Code |
4500016
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$120.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$40.98
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$32.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$28.29
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$170.00
|
| Rate for Payer: First Health Commercial |
$180.00
|
| Rate for Payer: First Health Workers Compensation |
$77.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$180.00
|
| Rate for Payer: GEHA Commercial |
$160.00
|
| Rate for Payer: GEHA Medicare |
$28.29
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$180.00
|
| Rate for Payer: Humana ChoiceCare |
$31.12
|
| Rate for Payer: Humana Medicare Advantage |
$28.29
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$47.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$33.13
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$28.29
|
| Rate for Payer: Multiplan All |
$182.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$48.09
|
| Rate for Payer: OMNI Networks Commercial |
$140.00
|
| Rate for Payer: One Health Plan PPO/POS |
$180.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$38.25
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$33.13
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$28.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$190.00
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$56.58
|
| Rate for Payer: Three Rivers Provider Network All |
$150.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$170.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$33.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$186.00
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$28.29
|
| Rate for Payer: Zelis Auto |
$80.00
|
| Rate for Payer: Zelis Medicare |
$24.05
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.95
|
| Rate for Payer: Zelis Worker's Compensation |
$54.60
|
|
|
OT HLTH BHVIOR IVNT FM W/PT F2F EA AD 15
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
CPT 96168
|
| Hospital Charge Code |
4500018
|
|
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
|
|
|
OT HLTH BHVIOR IVNT FM W/PT F2F EA AD 15
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
CPT 96168
|
| Hospital Charge Code |
4500018
|
|
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
|
|
|
OT HYDROTHERAPY, CONSTANT ATTENDANCE
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 97036
|
| Hospital Charge Code |
4597036
|
|
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
|
|
|
OT HYDROTHERAPY, CONSTANT ATTENDANCE
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 97036
|
| Hospital Charge Code |
4597036
|
|
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
|
|
|
OT INFRARED THERAPY
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 97026
|
| Hospital Charge Code |
4597026
|
|
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
|
|
|
OT INFRARED THERAPY
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 97026
|
| Hospital Charge Code |
4597026
|
|
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
|
|
|
OT IONTOPHORESIS
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 97033
|
| Hospital Charge Code |
4590177
|
|
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
|
|
|
OT IONTOPHORESIS
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 97033
|
| Hospital Charge Code |
4590177
|
|
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
|
|
|
OT MANUAL THERAPY
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
4590187
|
|
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
|
|
|
OT MANUAL THERAPY
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
4590187
|
|
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 MOTION FLUOROSCOPY/SWALLOW MBS
|
Facility
|
IP
|
$624.00
|
|
|
Service Code
|
CPT 92611
|
| Hospital Charge Code |
4590170
|
|
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
|
|
|
OT MOTION FLUOROSCOPY/SWALLOW MBS
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
CPT 92611
|
| Hospital Charge Code |
4590170
|
|
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
|
|
|
OT MUSCLE TESTING, EXTREMITY OR TRUNK
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 95831
|
| Hospital Charge Code |
4595831
|
|
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
|
|
|
OT MUSCLE TESTING, EXTREMITY OR TRUNK
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 95831
|
| Hospital Charge Code |
4595831
|
|
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
|
|
|
OT MUSCLE TESTING/HAND
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
CPT 95832
|
| Hospital Charge Code |
4500028
|
|
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
|
|
|
OT MUSCLE TESTING/HAND
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
CPT 95832
|
| Hospital Charge Code |
4500028
|
|
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
|
|
|
OT NEUROMUS RE ED EA 15 MIN
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 97112
|
| Hospital Charge Code |
4590185
|
|
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 NEUROMUS RE ED EA 15 MIN
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 97112
|
| Hospital Charge Code |
4590185
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.29 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$71.14
|
| 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 |
$71.14
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$56.36
|
| 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 |
$64.05
|
| 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 |
$57.51
|
| 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 |
$66.40
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$57.51
|
| 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 |
$57.51
|
| 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 |
$45.29
|
|
|
OTOLARYNGOLOGIC EXAM UNDER GENERAL ANEST
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
6192502
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$967.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$175.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$346.31
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$274.34
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$483.55
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$234.40
|
| Rate for Payer: GEHA Medicare |
$483.55
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Humana ChoiceCare |
$531.90
|
| Rate for Payer: Humana Medicare Advantage |
$483.55
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$812.36
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$279.93
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$483.55
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$822.03
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$323.22
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$279.93
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$483.55
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$967.10
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$473.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$279.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$483.55
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Medicare |
$411.02
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$580.26
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
OTOLARYNGOLOGIC EXAM UNDER GENERAL ANEST
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
6192502
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$79.99 |
| Max. Negotiated Rate |
$278.35 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$249.05
|
| Rate for Payer: First Health Commercial |
$263.70
|
| Rate for Payer: First Health Workers Compensation |
$113.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$263.70
|
| Rate for Payer: GEHA Commercial |
$205.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$263.70
|
| Rate for Payer: Multiplan All |
$266.63
|
| Rate for Payer: OMNI Networks Commercial |
$205.10
|
| Rate for Payer: One Health Plan PPO/POS |
$263.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$278.35
|
| Rate for Payer: Three Rivers Provider Network All |
$219.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$272.49
|
| Rate for Payer: Zelis Auto |
$117.20
|
| Rate for Payer: Zelis Worker's Compensation |
$79.99
|
|
|
OT ORTHOTIC TRNG 15 MIN
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 97760
|
| Hospital Charge Code |
4590186
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.03 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$99.24
|
| 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 |
$99.24
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$78.62
|
| 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 |
$89.15
|
| 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 |
$80.22
|
| 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 |
$92.62
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$80.22
|
| 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 |
$80.22
|
| 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 |
$63.03
|
|
|
OT ORTHOTIC TRNG 15 MIN
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 97760
|
| Hospital Charge Code |
4590186
|
|
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
|
|
