|
OT THERAPTC MASSGE E15M
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 97124
|
| Hospital Charge Code |
4500044
|
|
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
|
|
|
OT THER EX E15
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
4500042
|
|
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
|
|
|
OT THER EX E15
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
4500042
|
|
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
|
|
|
OT THER INVTJ W/FOCUS COG FUNCJ
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 97127
|
| Hospital Charge Code |
4500045
|
|
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
|
|
|
OT THER INVTJ W/FOCUS COG FUNCJ
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 97127
|
| Hospital Charge Code |
4500045
|
|
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
|
|
|
OT THER IVNTJ COG FUNCJ CNTCT 1ST 15 MIN
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 97129
|
| Hospital Charge Code |
4500001
|
|
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
|
|
|
OT THER IVNTJ COG FUNCJ CNTCT 1ST 15 MIN
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 97129
|
| Hospital Charge Code |
4500001
|
|
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
|
|
|
OT THER IVNTJ COG FUNCJ CNTCT EA ADDL 15
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 97130
|
| Hospital Charge Code |
4500002
|
|
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
|
|
|
OT THER IVNTJ COG FUNCJ CNTCT EA ADDL 15
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 97130
|
| Hospital Charge Code |
4500002
|
|
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
|
|
|
OT ULTRAVIOLET THERAPY
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 97028
|
| Hospital Charge Code |
4597028
|
|
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
|
|
|
OT ULTRAVIOLET THERAPY
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 97028
|
| Hospital Charge Code |
4597028
|
|
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
|
|
|
OT UNLISTED MODALITY, CONSTANT ATTEND
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 97039
|
| Hospital Charge Code |
4590180
|
|
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
|
|
|
OT UNLISTED MODALITY, CONSTANT ATTEND
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 97039
|
| Hospital Charge Code |
4590180
|
|
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
|
|
|
OT UNLISTED PHYSICAL MEDICINE/REHABILITA
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT 97799
|
| Hospital Charge Code |
4597799
|
|
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
|
|
|
OT UNLISTED PHYSICAL MEDICINE/REHABILITA
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 97799
|
| Hospital Charge Code |
4597799
|
|
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
|
|
|
OT UNLISTED THERAPEUTIC PROCEDURE (SPECI
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 97139
|
| Hospital Charge Code |
4597139
|
|
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
|
|
|
OT UNLISTED THERAPEUTIC PROCEDURE (SPECI
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 97139
|
| Hospital Charge Code |
4597139
|
|
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
|
|
|
OT US-15 MIN
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 97035
|
| Hospital Charge Code |
4597800
|
|
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
|
|
|
OT US-15 MIN
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 97035
|
| Hospital Charge Code |
4597800
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$76.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$23.54
|
| Rate for Payer: Cash Price |
$76.80
|
| 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 |
$26.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$115.20
|
| Rate for Payer: GEHA Commercial |
$102.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$115.20
|
| Rate for Payer: Humana ChoiceCare |
$33.28
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$24.02
|
| Rate for Payer: Multiplan All |
$116.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$76.80
|
| Rate for Payer: OMNI Networks Commercial |
$89.60
|
| Rate for Payer: One Health Plan PPO/POS |
$115.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$27.73
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$24.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$121.60
|
| Rate for Payer: Three Rivers Provider Network All |
$96.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$112.64
|
| Rate for Payer: United Healthcare Commercial |
$108.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.02
|
| Rate for Payer: United Payors & United Providers UP&UP |
$119.04
|
| Rate for Payer: Zelis Auto |
$51.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$64.00
|
| Rate for Payer: Zelis Worker's Compensation |
$18.68
|
|
|
OT WHEELCHAIR MNGMT TRA
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 97542
|
| Hospital Charge Code |
4510006
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$32.45 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$40.97
|
| 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 |
$40.97
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$32.45
|
| 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 |
$60.09
|
| 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 |
$33.11
|
| 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 |
$38.23
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$33.11
|
| 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 |
$33.11
|
| 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 |
$42.49
|
|
|
OT WHEELCHAIR MNGMT TRA
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 97542
|
| Hospital Charge Code |
4510006
|
|
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 WHIRLPOOL THERAPY
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 97022
|
| Hospital Charge Code |
4597022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$22.41 |
| Max. Negotiated Rate |
$208.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$131.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$28.09
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$186.15
|
| Rate for Payer: First Health Commercial |
$197.10
|
| Rate for Payer: First Health Workers Compensation |
$31.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$197.10
|
| Rate for Payer: GEHA Commercial |
$175.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$197.10
|
| Rate for Payer: Humana ChoiceCare |
$56.94
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$28.66
|
| Rate for Payer: Multiplan All |
$199.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$131.40
|
| Rate for Payer: OMNI Networks Commercial |
$153.30
|
| Rate for Payer: One Health Plan PPO/POS |
$197.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$33.10
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$28.66
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$208.05
|
| Rate for Payer: Three Rivers Provider Network All |
$164.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$192.72
|
| Rate for Payer: United Healthcare Commercial |
$186.15
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$203.67
|
| Rate for Payer: Zelis Auto |
$87.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$109.50
|
| Rate for Payer: Zelis Worker's Compensation |
$22.41
|
|
|
OT WHIRLPOOL THERAPY
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 97022
|
| Hospital Charge Code |
4597022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$59.79 |
| Max. Negotiated Rate |
$208.05 |
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$186.15
|
| Rate for Payer: First Health Commercial |
$197.10
|
| Rate for Payer: First Health Workers Compensation |
$84.56
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$197.10
|
| Rate for Payer: GEHA Commercial |
$153.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$197.10
|
| Rate for Payer: Multiplan All |
$199.29
|
| Rate for Payer: OMNI Networks Commercial |
$153.30
|
| Rate for Payer: One Health Plan PPO/POS |
$197.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$208.05
|
| Rate for Payer: Three Rivers Provider Network All |
$164.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$203.67
|
| Rate for Payer: Zelis Auto |
$87.60
|
| Rate for Payer: Zelis Worker's Compensation |
$59.79
|
|
|
OT WORK HARDENING EACH ADDITIONAL HOUR
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
CPT 97546
|
| Hospital Charge Code |
4597546
|
|
Hospital Revenue Code
|
432
|
| Min. Negotiated Rate |
$56.03 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: First Health Workers Compensation |
$79.24
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$608.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Humana ChoiceCare |
$197.86
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$456.60
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$669.68
|
| Rate for Payer: United Healthcare Commercial |
$646.85
|
| Rate for Payer: United Healthcare Managed Medicaid |
$190.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$380.50
|
| Rate for Payer: Zelis Worker's Compensation |
$56.03
|
|
|
OT WORK HARDENING EACH ADDITIONAL HOUR
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
CPT 97546
|
| Hospital Charge Code |
4597546
|
|
Hospital Revenue Code
|
432
|
| Min. Negotiated Rate |
$207.75 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: First Health Workers Compensation |
$293.82
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$532.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
| Rate for Payer: Zelis Worker's Compensation |
$207.75
|
|
