2007 new mexicodisclosure - new mexico chiropractic ... · 2007 procedure code/mod par fee nonpar...

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2007 PROCEDURE CODE/MOD PAR FEE NONPAR CHARGE FEE FEE PROCEDURE CODE/MOD PAR FEE NONPAR CHARGE FEE FEE PROCEDURE CODE/MOD PAR FEE NONPAR CHARGE FEE FEE New Mexico Disclosure 0073T $569.71 $541.22 $622.40 0144T $266.31 $252.99 $290.94 0144T TC $220.45 $209.43 $240.84 0144T 26 $45.87 $43.58 $50.12 0145T $388.80 $369.36 $424.76 0145T TC $283.99 $269.79 $310.26 0145T 26 $104.82 $99.58 $114.52 0146T 26 $140.74 $133.70 $153.76 0146T TC $577.56 $548.68 $630.98 0146T $718.30 $682.39 $784.75 0147T $718.30 $682.39 $784.75 0147T TC $577.56 $548.68 $630.98 0147T 26 $140.74 $133.70 $153.76 0148T $718.30 $682.39 $784.75 0148T TC $577.56 $548.68 $630.98 0148T 26 $140.74 $133.70 $153.76 0149T $718.30 $682.39 $784.75 0149T TC $577.56 $548.68 $630.98 0149T 26 $140.74 $133.70 $153.76 0150T 26 $140.74 $133.70 $153.76 0150T TC $577.56 $548.68 $630.98 0150T $718.30 $682.39 $784.75 0151T 26 $41.73 $39.64 $45.59 0151T TC $125.81 $119.52 $137.45 0151T $167.54 $159.16 $183.03 10021 $118.56 $112.63 $129.52 # 10021 $63.36 $60.19 $69.22 10022 $126.97 $120.62 $138.71 # 10022 $59.33 $56.36 $64.81 10040 $78.90 $74.96 $86.20 # 10040 $70.49 $66.97 $77.02 10060 $87.96 $83.56 $96.09 # 10060 $77.20 $73.34 $84.34 10061 $154.89 $147.15 $169.22 # 10061 $142.10 $135.00 $155.25 10080 $144.84 $137.60 $158.24 # 10080 $81.57 $77.49 $89.11 10081 $224.06 $212.86 $244.79 # 10081 $142.28 $135.17 $155.45 10120 $117.41 $111.54 $128.27 # 10120 $78.71 $74.77 $85.99 10121 $221.60 $210.52 $242.10 # 10121 $162.37 $154.25 $177.39 10140 $122.62 $116.49 $133.96 # 10140 $102.43 $97.31 $111.91 10160 $102.22 $97.11 $111.68 # 10160 $82.70 $78.57 $90.36 10180 $191.96 $182.36 $209.71 # 10180 $154.27 $146.56 $168.54 11000 $43.66 $41.48 $47.70 # 11000 $29.87 $28.38 $32.64 11001 $19.31 $18.34 $21.09 # 11001 $14.93 $14.18 $16.31 11004 $515.85 $490.06 $563.57 11005 $693.49 $658.82 $757.64 11006 $643.59 $611.41 $703.12 11008 $253.48 $240.81 $276.93 11010 $394.73 $374.99 $431.24 # 11010 $250.70 $238.17 $273.90 11011 $458.13 $435.22 $500.50 # 11011 $269.34 $255.87 $294.25 11012 $653.84 $621.15 $714.32 # 11012 $396.40 $376.58 $433.07 11040 $37.90 $36.01 $41.41 # 11040 $25.79 $24.50 $28.18 11041 $46.68 $44.35 $51.00 # 11041 $33.90 $32.21 $37.04 11042 $64.27 $61.06 $70.22 # 11042 $44.75 $42.51 $48.89 11043 $230.23 $218.72 $251.53 # 11043 $202.30 $192.19 $221.02 11044 $308.69 $293.26 $337.25 # 11044 $280.09 $266.09 $306.00 11055 $37.65 $35.77 $41.14 # 11055 $21.83 $20.74 $23.85 11056 $46.74 $44.40 $51.06 # 11056 $30.58 $29.05 $33.41 11057 $57.50 $54.63 $62.82 # 11057 $39.67 $37.69 $43.34 11100 $76.12 $72.31 $83.16 # 11100 $41.45 $39.38 $45.29 11101 $26.47 $25.15 $28.92 # 11101 $21.42 $20.35 $23.40 11200 $64.92 $61.67 $70.92 # 11200 $55.16 $52.40 $60.26 11201 $15.90 $15.11 $17.38 # 11201 $14.56 $13.83 $15.90 11300 $53.43 $50.76 $58.37 # 11300 $25.50 $24.23 $27.86 11301 $70.86 $67.32 $77.42 # 11301 $42.92 $40.77 $46.89 11302 $85.08 $80.83 $92.95 # 11302 $53.11 $50.45 $58.02 11303 $101.65 $96.57 $111.06 # 11303 $62.62 $59.49 $68.41 11305 $55.70 $52.92 $60.86 # 11305 $33.82 $32.13 $36.95 11306 $75.77 $71.98 $82.78 # 11306 $49.86 $47.37 $54.48 11307 $88.48 $84.06 $96.67 # 11307 $57.86 $54.97 $63.22 11308 $103.95 $98.75 $113.56 # 11308 $71.98 $68.38 $78.64 11310 $66.06 $62.76 $72.17 # 11310 $37.12 $35.26 $40.55 11311 $82.39 $78.27 $90.01 # 11311 $53.78 $51.09 $58.75 11312 $95.09 $90.34 $103.89 # 11312 $61.78 $58.69 $67.49 11313 $122.61 $116.48 $133.95 # 11313 $83.23 $79.07 $90.93 11400 $97.52 $92.64 $106.54 # 11400 $61.85 $58.76 $67.57 11401 $115.78 $109.99 $126.49 # 11401 $81.12 $77.06 $88.62 11402 $128.90 $122.46 $140.83 # 11402 $90.20 $85.69 $98.54 11403 $149.22 $141.76 $163.02 # 11403 $113.88 $108.19 $124.42 11404 $170.08 $161.58 $185.82 # 11404 $127.01 $120.66 $138.76 11406 $235.59 $223.81 $257.38 # 11406 $188.14 $178.73 $205.54 11420 $97.01 $92.16 $105.98 # 11420 $68.41 $64.99 $74.74 11421 $124.27 $118.06 $135.77 # 11421 $91.63 $87.05 $100.11 11422 $138.49 $131.57 $151.31 # 11422 $107.87 $102.48 $117.85 11423 $163.52 $155.34 $178.64 # 11423 $126.50 $120.18 $138.21 11424 $187.29 $177.93 $204.62 # 11424 $147.24 $139.88 $160.86 11426 $270.36 $256.84 $295.37 # 11426 $224.93 $213.68 $245.73 11440 $109.89 $104.40 $120.06 # 11440 $81.62 $77.54 $89.17 11441 $134.58 $127.85 $147.03 # 11441 $106.31 $100.99 $116.14 11442 $150.61 $143.08 $164.54 # 11442 $117.96 $112.06 $128.87 11443 $183.76 $174.57 $200.76 # 11443 $147.41 $140.04 $161.05 11444 $232.73 $221.09 $254.25 # 11444 $190.32 $180.80 $207.92 11446 $312.46 $296.84 $341.37 # 11446 $268.71 $255.27 $293.56 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION. Page 1 of 70

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Page 1: 2007 New MexicoDisclosure - New Mexico Chiropractic ... · 2007 procedure code/mod par fee nonpar charge fee fee procedure code/mod par fee nonpar charge fee fee procedure code/mod

2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

0073T $569.71 $541.22 $622.400144T $266.31 $252.99 $290.940144T TC $220.45 $209.43 $240.840144T 26 $45.87 $43.58 $50.120145T $388.80 $369.36 $424.760145T TC $283.99 $269.79 $310.260145T 26 $104.82 $99.58 $114.520146T 26 $140.74 $133.70 $153.760146T TC $577.56 $548.68 $630.980146T $718.30 $682.39 $784.750147T $718.30 $682.39 $784.750147T TC $577.56 $548.68 $630.980147T 26 $140.74 $133.70 $153.760148T $718.30 $682.39 $784.750148T TC $577.56 $548.68 $630.980148T 26 $140.74 $133.70 $153.760149T $718.30 $682.39 $784.750149T TC $577.56 $548.68 $630.980149T 26 $140.74 $133.70 $153.760150T 26 $140.74 $133.70 $153.760150T TC $577.56 $548.68 $630.980150T $718.30 $682.39 $784.750151T 26 $41.73 $39.64 $45.590151T TC $125.81 $119.52 $137.450151T $167.54 $159.16 $183.0310021 $118.56 $112.63 $129.52

# 10021 $63.36 $60.19 $69.2210022 $126.97 $120.62 $138.71

# 10022 $59.33 $56.36 $64.8110040 $78.90 $74.96 $86.20

# 10040 $70.49 $66.97 $77.0210060 $87.96 $83.56 $96.09

# 10060 $77.20 $73.34 $84.3410061 $154.89 $147.15 $169.22

# 10061 $142.10 $135.00 $155.2510080 $144.84 $137.60 $158.24

# 10080 $81.57 $77.49 $89.1110081 $224.06 $212.86 $244.79

# 10081 $142.28 $135.17 $155.4510120 $117.41 $111.54 $128.27

# 10120 $78.71 $74.77 $85.9910121 $221.60 $210.52 $242.10

# 10121 $162.37 $154.25 $177.3910140 $122.62 $116.49 $133.96

# 10140 $102.43 $97.31 $111.9110160 $102.22 $97.11 $111.68

# 10160 $82.70 $78.57 $90.3610180 $191.96 $182.36 $209.71

# 10180 $154.27 $146.56 $168.54

11000 $43.66 $41.48 $47.70# 11000 $29.87 $28.38 $32.64

11001 $19.31 $18.34 $21.09# 11001 $14.93 $14.18 $16.31

11004 $515.85 $490.06 $563.5711005 $693.49 $658.82 $757.6411006 $643.59 $611.41 $703.1211008 $253.48 $240.81 $276.9311010 $394.73 $374.99 $431.24

# 11010 $250.70 $238.17 $273.9011011 $458.13 $435.22 $500.50

# 11011 $269.34 $255.87 $294.2511012 $653.84 $621.15 $714.32

# 11012 $396.40 $376.58 $433.0711040 $37.90 $36.01 $41.41

# 11040 $25.79 $24.50 $28.1811041 $46.68 $44.35 $51.00

# 11041 $33.90 $32.21 $37.0411042 $64.27 $61.06 $70.22

# 11042 $44.75 $42.51 $48.8911043 $230.23 $218.72 $251.53

# 11043 $202.30 $192.19 $221.0211044 $308.69 $293.26 $337.25

# 11044 $280.09 $266.09 $306.0011055 $37.65 $35.77 $41.14

# 11055 $21.83 $20.74 $23.8511056 $46.74 $44.40 $51.06

# 11056 $30.58 $29.05 $33.4111057 $57.50 $54.63 $62.82

# 11057 $39.67 $37.69 $43.3411100 $76.12 $72.31 $83.16

# 11100 $41.45 $39.38 $45.2911101 $26.47 $25.15 $28.92

# 11101 $21.42 $20.35 $23.4011200 $64.92 $61.67 $70.92

# 11200 $55.16 $52.40 $60.2611201 $15.90 $15.11 $17.38

# 11201 $14.56 $13.83 $15.9011300 $53.43 $50.76 $58.37

# 11300 $25.50 $24.23 $27.8611301 $70.86 $67.32 $77.42

# 11301 $42.92 $40.77 $46.8911302 $85.08 $80.83 $92.95

# 11302 $53.11 $50.45 $58.0211303 $101.65 $96.57 $111.06

# 11303 $62.62 $59.49 $68.4111305 $55.70 $52.92 $60.86

# 11305 $33.82 $32.13 $36.9511306 $75.77 $71.98 $82.78

# 11306 $49.86 $47.37 $54.4811307 $88.48 $84.06 $96.67

# 11307 $57.86 $54.97 $63.2211308 $103.95 $98.75 $113.56

# 11308 $71.98 $68.38 $78.6411310 $66.06 $62.76 $72.17

# 11310 $37.12 $35.26 $40.5511311 $82.39 $78.27 $90.01

# 11311 $53.78 $51.09 $58.7511312 $95.09 $90.34 $103.89

# 11312 $61.78 $58.69 $67.4911313 $122.61 $116.48 $133.95

# 11313 $83.23 $79.07 $90.9311400 $97.52 $92.64 $106.54

# 11400 $61.85 $58.76 $67.5711401 $115.78 $109.99 $126.49

# 11401 $81.12 $77.06 $88.6211402 $128.90 $122.46 $140.83

# 11402 $90.20 $85.69 $98.5411403 $149.22 $141.76 $163.02

# 11403 $113.88 $108.19 $124.4211404 $170.08 $161.58 $185.82

# 11404 $127.01 $120.66 $138.7611406 $235.59 $223.81 $257.38

# 11406 $188.14 $178.73 $205.5411420 $97.01 $92.16 $105.98

# 11420 $68.41 $64.99 $74.7411421 $124.27 $118.06 $135.77

# 11421 $91.63 $87.05 $100.1111422 $138.49 $131.57 $151.31

# 11422 $107.87 $102.48 $117.8511423 $163.52 $155.34 $178.64

# 11423 $126.50 $120.18 $138.2111424 $187.29 $177.93 $204.62

# 11424 $147.24 $139.88 $160.8611426 $270.36 $256.84 $295.37

# 11426 $224.93 $213.68 $245.7311440 $109.89 $104.40 $120.06

# 11440 $81.62 $77.54 $89.1711441 $134.58 $127.85 $147.03

# 11441 $106.31 $100.99 $116.1411442 $150.61 $143.08 $164.54

# 11442 $117.96 $112.06 $128.8711443 $183.76 $174.57 $200.76

# 11443 $147.41 $140.04 $161.0511444 $232.73 $221.09 $254.25

# 11444 $190.32 $180.80 $207.9211446 $312.46 $296.84 $341.37

# 11446 $268.71 $255.27 $293.56

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

Page 1 of 70

Page 2: 2007 New MexicoDisclosure - New Mexico Chiropractic ... · 2007 procedure code/mod par fee nonpar charge fee fee procedure code/mod par fee nonpar charge fee fee procedure code/mod

2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

11450 $288.49 $274.07 $315.18# 11450 $189.55 $180.07 $207.08

11451 $383.93 $364.73 $419.44# 11451 $253.35 $240.68 $276.78

11462 $283.99 $269.79 $310.26# 11462 $182.02 $172.92 $198.86

11463 $394.02 $374.32 $430.47# 11463 $259.07 $246.12 $283.04

11470 $312.68 $297.05 $341.61# 11470 $217.78 $206.89 $237.92

11471 $406.89 $386.55 $444.53# 11471 $278.34 $264.42 $304.08

11600 $146.67 $139.34 $160.24# 11600 $91.48 $86.91 $99.95

11601 $170.23 $161.72 $185.98# 11601 $116.72 $110.88 $127.51

11602 $183.45 $174.28 $200.42# 11602 $126.24 $119.93 $137.92

11603 $211.43 $200.86 $230.99# 11603 $149.17 $141.71 $162.97

11604 $234.99 $223.24 $256.73# 11604 $164.65 $156.42 $179.88

11606 $330.15 $313.64 $360.69# 11606 $246.02 $233.72 $268.78

11620 $146.71 $139.37 $160.28# 11620 $91.18 $86.62 $99.61

11621 $170.95 $162.40 $186.76# 11621 $117.78 $111.89 $128.67

11622 $192.70 $183.07 $210.53# 11622 $135.15 $128.39 $147.65

11623 $229.68 $218.20 $250.93# 11623 $167.43 $159.06 $182.92

11624 $262.58 $249.45 $286.87# 11624 $193.25 $183.59 $211.13

11626 $328.89 $312.45 $359.32# 11626 $250.48 $237.96 $273.65

11640 $151.54 $143.96 $165.55# 11640 $98.04 $93.14 $107.11

11641 $184.74 $175.50 $201.83# 11641 $130.22 $123.71 $142.27

11642 $213.68 $203.00 $233.45# 11642 $152.77 $145.13 $166.90

11643 $255.42 $242.65 $279.05# 11643 $190.81 $181.27 $208.46

11644 $319.49 $303.52 $349.05# 11644 $241.41 $229.34 $263.74

11646 $426.70 $405.37 $466.18# 11646 $346.27 $328.96 $378.30

11719 $15.77 $14.98 $17.23

# 11719 $8.71 $8.27 $9.5111720 $24.78 $23.54 $27.07

# 11720 $16.03 $15.23 $17.5111721 $36.72 $34.88 $40.11

# 11721 $27.63 $26.25 $30.1911730 $79.54 $75.56 $86.89

# 11730 $55.65 $52.87 $60.8011732 $37.48 $35.61 $40.95

# 11732 $28.39 $26.97 $31.0211740 $34.37 $32.65 $37.55

# 11740 $26.29 $24.98 $28.7311750 $168.95 $160.50 $184.58

# 11750 $149.43 $141.96 $163.2511752 $240.67 $228.64 $262.94

# 11752 $229.57 $218.09 $250.8011755 $106.26 $100.95 $116.09

# 11755 $75.30 $71.54 $82.2711760 $156.81 $148.97 $171.32

# 11760 $118.79 $112.85 $129.7811762 $215.62 $204.84 $235.57

# 11762 $185.00 $175.75 $202.1111765 $94.56 $89.83 $103.30

# 11765 $54.85 $52.11 $59.9311770 $217.93 $207.03 $238.08

# 11770 $151.64 $144.06 $165.6711771 $427.12 $405.76 $466.62

# 11771 $343.32 $326.15 $375.0711772 $532.45 $505.83 $581.70

# 11772 $450.34 $427.82 $491.9911900 $42.71 $40.57 $46.66

# 11900 $25.88 $24.59 $28.2811901 $53.53 $50.85 $58.48

# 11901 $40.74 $38.70 $44.5111920 $176.70 $167.87 $193.05

# 11920 $100.31 $95.29 $109.5811921 $198.45 $188.53 $216.81

# 11921 $118.69 $112.76 $129.6711922 $55.69 $52.91 $60.85

# 11922 $27.42 $26.05 $29.9611950 $66.81 $63.47 $72.99

# 11950 $43.59 $41.41 $47.6211951 $92.01 $87.41 $100.52

# 11951 $61.72 $58.63 $67.4211952 $124.53 $118.30 $136.05

# 11952 $87.17 $82.81 $95.2311954 $147.64 $140.26 $161.30

# 11954 $100.53 $95.50 $109.8311960 $771.56 $732.98 $842.9311970 $511.26 $485.70 $558.56

11971 $412.98 $392.33 $451.18# 11971 $250.43 $237.91 $273.60

11976 $125.52 $119.24 $137.13# 11976 $88.84 $84.40 $97.06

11980 $91.76 $87.17 $100.25# 11980 $73.25 $69.59 $80.03

11981 $113.63 $107.95 $124.14# 11981 $76.62 $72.79 $83.71

11982 $132.60 $125.97 $144.87# 11982 $93.56 $88.88 $102.21

11983 $200.32 $190.30 $218.85# 11983 $168.69 $160.26 $184.30

12001 $128.36 $121.94 $140.23# 12001 $89.32 $84.85 $97.58

12002 $136.35 $129.53 $148.96# 12002 $99.67 $94.69 $108.89

12004 $159.99 $151.99 $174.79# 12004 $117.25 $111.39 $128.10

12005 $199.70 $189.72 $218.18# 12005 $146.53 $139.20 $160.08

12006 $248.17 $235.76 $271.12# 12006 $186.25 $176.94 $203.48

12007 $280.46 $266.44 $306.41# 12007 $213.83 $203.14 $233.61

12011 $135.63 $128.85 $148.18# 12011 $92.22 $87.61 $100.75

12013 $149.31 $141.84 $163.12# 12013 $105.56 $100.28 $115.32

12014 $176.31 $167.49 $192.61# 12014 $127.18 $120.82 $138.94

12015 $221.50 $210.43 $241.99# 12015 $160.25 $152.24 $175.08

12016 $262.60 $249.47 $286.89# 12016 $195.97 $186.17 $214.10

12017 $236.98 $225.13 $258.9012018 $283.77 $269.58 $310.0212020 $227.70 $216.32 $248.77

# 12020 $163.43 $155.26 $178.5512021 $132.88 $126.24 $145.18

# 12021 $118.07 $112.17 $129.0012031 $170.10 $161.60 $185.84

# 12031 $118.94 $112.99 $129.9412032 $231.23 $219.67 $252.62

# 12032 $154.84 $147.10 $169.1712034 $227.52 $216.14 $248.56

# 12034 $161.90 $153.81 $176.8812035 $305.44 $290.17 $333.70

# 12035 $202.13 $192.02 $220.8212036 $342.10 $325.00 $373.75

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

Page 2 of 70

Page 3: 2007 New MexicoDisclosure - New Mexico Chiropractic ... · 2007 procedure code/mod par fee nonpar charge fee fee procedure code/mod par fee nonpar charge fee fee procedure code/mod

2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

# 12036 $239.79 $227.80 $261.9712037 $385.16 $365.90 $420.79

# 12037 $278.48 $264.56 $304.2412041 $184.40 $175.18 $201.46

# 12041 $131.23 $124.67 $143.3712042 $219.80 $208.81 $240.13

# 12042 $154.51 $146.78 $168.8012044 $242.50 $230.38 $264.94

# 12044 $173.51 $164.83 $189.5512045 $313.31 $297.64 $342.29

# 12045 $213.02 $202.37 $232.7312046 $374.50 $355.78 $409.15

# 12046 $252.00 $239.40 $275.3112047 $390.15 $370.64 $426.24

# 12047 $277.41 $263.54 $303.0712051 $208.67 $198.24 $227.98

# 12051 $144.40 $137.18 $157.7612052 $224.05 $212.85 $244.78

# 12052 $159.43 $151.46 $174.1812053 $241.41 $229.34 $263.74

# 12053 $171.08 $162.53 $186.9112054 $263.53 $250.35 $287.90

# 12054 $186.80 $177.46 $204.0812055 $330.11 $313.60 $360.64

# 12055 $237.90 $226.01 $259.9112056 $421.34 $400.27 $460.31

# 12056 $295.81 $281.02 $323.1712057 $439.92 $417.92 $480.61

# 12057 $340.98 $323.93 $372.5213100 $255.20 $242.44 $278.81

# 13100 $194.63 $184.90 $212.6413101 $310.38 $294.86 $339.09

# 13101 $235.67 $223.89 $257.4713102 $87.84 $83.45 $95.97

# 13102 $65.96 $62.66 $72.0613120 $265.35 $252.08 $289.89

# 13120 $203.09 $192.94 $221.8813121 $335.93 $319.13 $367.00

# 13121 $258.53 $245.60 $282.4413122 $104.08 $98.88 $113.71

# 13122 $75.47 $71.70 $82.4613131 $290.73 $276.19 $317.62

# 13131 $230.49 $218.97 $251.8213132 $447.67 $425.29 $489.08

# 13132 $379.01 $360.06 $414.0713133 $138.54 $131.61 $151.35

# 13133 $114.99 $109.24 $125.6313150 $304.25 $289.04 $332.40

# 13150 $234.59 $222.86 $256.29

13151 $330.24 $313.73 $360.79# 13151 $268.99 $255.54 $293.87

13152 $445.41 $423.14 $486.61# 13152 $364.98 $346.73 $398.74

13153 $155.06 $147.31 $169.41# 13153 $126.46 $120.14 $138.16

13160 $695.59 $660.81 $759.9314000 $526.30 $499.99 $574.99

# 14000 $441.83 $419.74 $482.7014001 $686.22 $651.91 $749.70

# 14001 $597.38 $567.51 $652.6414020 $584.66 $555.43 $638.74

# 14020 $505.91 $480.61 $552.7014021 $765.99 $727.69 $836.84

# 14021 $691.28 $656.72 $755.2314040 $616.92 $586.07 $673.98

# 14040 $549.61 $522.13 $600.4514041 $839.01 $797.06 $916.62

# 14041 $755.22 $717.46 $825.0814060 $635.47 $603.70 $694.26

# 14060 $580.62 $551.59 $634.3314061 $910.09 $864.59 $994.28

# 14061 $818.21 $777.30 $893.9014300 $886.90 $842.56 $968.94

# 14300 $803.10 $762.95 $877.3914350 $653.04 $620.39 $713.4515002 $279.30 $265.34 $305.14

# 15002 $196.17 $186.36 $214.3115003 $61.92 $58.82 $67.64

# 15003 $40.38 $38.36 $44.1115004 $337.34 $320.47 $368.54

# 15004 $243.11 $230.95 $265.5915005 $104.99 $99.74 $114.70

# 15005 $80.76 $76.72 $88.2315040 $223.96 $212.76 $244.67

# 15040 $113.57 $107.89 $124.0715050 $441.33 $419.26 $482.15

# 15050 $374.02 $355.32 $408.6215100 $775.48 $736.71 $847.22

# 15100 $629.42 $597.95 $687.6415101 $182.17 $173.06 $199.02

# 15101 $103.76 $98.57 $113.3615110 $759.98 $721.98 $830.28

# 15110 $646.91 $614.56 $706.7415111 $111.63 $106.05 $121.96

# 15111 $97.16 $92.30 $106.1515115 $730.55 $694.02 $798.12

# 15115 $662.58 $629.45 $723.8715116 $146.75 $139.41 $160.32

# 15116 $132.28 $125.67 $144.5215120 $778.16 $739.25 $850.14

# 15120 $671.82 $638.23 $733.9615121 $245.65 $233.37 $268.38

# 15121 $160.84 $152.80 $175.7215130 $601.76 $571.67 $657.42

# 15130 $492.72 $468.08 $538.2915131 $91.15 $86.59 $99.58

# 15131 $78.69 $74.76 $85.9715135 $742.26 $705.15 $810.92

# 15135 $677.98 $644.08 $740.6915136 $86.10 $81.80 $94.07

# 15136 $79.37 $75.40 $86.7115150 $629.79 $598.30 $688.05

# 15150 $567.87 $539.48 $620.4015151 $118.27 $112.36 $129.21

# 15151 $105.15 $99.89 $114.8715152 $145.40 $138.13 $158.85

# 15152 $131.27 $124.71 $143.4215155 $640.10 $608.10 $699.32

# 15155 $607.12 $576.76 $663.2715156 $155.08 $147.33 $169.43

# 15156 $145.32 $138.05 $158.7615157 $171.87 $163.28 $187.77

# 15157 $158.74 $150.80 $173.4215170 $350.15 $332.64 $382.54

# 15170 $302.37 $287.25 $330.3415171 $81.90 $77.81 $89.48

# 15171 $79.21 $75.25 $86.5415175 $481.56 $457.48 $526.10

# 15175 $433.10 $411.45 $473.1715176 $130.06 $123.56 $142.09

# 15176 $125.02 $118.77 $136.5915200 $659.57 $626.59 $720.58

# 15200 $549.18 $521.72 $599.9815201 $133.88 $127.19 $146.27

# 15201 $71.96 $68.36 $78.6115220 $618.68 $587.75 $675.91

# 15220 $524.12 $497.91 $572.6015221 $121.61 $115.53 $132.86

# 15221 $64.40 $61.18 $70.3615240 $735.43 $698.66 $803.46

# 15240 $652.64 $620.01 $713.0115241 $154.08 $146.38 $168.34

# 15241 $100.91 $95.86 $110.2415260 $778.91 $739.96 $850.95

# 15260 $706.89 $671.55 $772.2815261 $176.06 $167.26 $192.35

# 15261 $128.27 $121.86 $140.14

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

15300 $284.13 $269.92 $310.41# 15300 $249.13 $236.67 $272.17

15301 $54.59 $51.86 $59.64# 15301 $51.90 $49.31 $56.71

15320 $325.18 $308.92 $355.26# 15320 $285.80 $271.51 $312.24

15321 $81.39 $77.32 $88.92# 15321 $77.35 $73.48 $84.50

15330 $259.41 $246.44 $283.41# 15330 $224.75 $213.51 $245.54

15331 $54.26 $51.55 $59.28# 15331 $51.90 $49.31 $56.71

15335 $288.27 $273.86 $314.94# 15335 $250.91 $238.36 $274.11

15336 $79.11 $75.15 $86.42# 15336 $74.07 $70.37 $80.93

15340 $274.70 $260.97 $300.12# 15340 $234.31 $222.59 $255.98

15341 $40.59 $38.56 $44.34# 15341 $25.45 $24.18 $27.81

15360 $298.55 $283.62 $326.16# 15360 $253.45 $240.78 $276.90

15361 $63.22 $60.06 $69.07# 15361 $58.51 $55.58 $63.92

15365 $310.41 $294.89 $339.12# 15365 $266.66 $253.33 $291.33

15366 $78.49 $74.57 $85.76# 15366 $73.78 $70.09 $80.60

15400 $308.02 $292.62 $336.51# 15400 $297.92 $283.02 $325.47

15401 $94.98 $90.23 $103.76# 15401 $52.91 $50.26 $57.80

15420 $347.64 $330.26 $379.80# 15420 $312.98 $297.33 $341.93

15421 $101.58 $96.50 $110.98# 15421 $78.36 $74.44 $85.61

15430 $457.89 $435.00 $500.25# 15430 $445.78 $423.49 $487.01

15570 $758.60 $720.67 $828.77# 15570 $611.20 $580.64 $667.74

15572 $701.56 $666.48 $766.45# 15572 $598.58 $568.65 $653.95

15574 $756.60 $718.77 $826.59# 15574 $654.29 $621.58 $714.82

15576 $671.72 $638.13 $733.85# 15576 $573.12 $544.46 $626.13

15600 $311.91 $296.31 $340.76# 15600 $175.61 $166.83 $191.85

15610 $261.00 $247.95 $285.14

# 15610 $207.49 $197.12 $226.6915620 $385.60 $366.32 $421.27

# 15620 $265.79 $252.50 $290.3815630 $382.79 $363.65 $418.20

# 15630 $286.88 $272.54 $313.4215650 $412.32 $391.70 $450.46

# 15650 $314.39 $298.67 $343.4715731 $932.20 $885.59 $1,018.43

# 15731 $845.71 $803.42 $923.9315732 $1,319.43 $1,253.46 $1,441.48

# 15732 $1,142.42 $1,085.30 $1,248.1015734 $1,347.89 $1,280.50 $1,472.58

# 15734 $1,170.87 $1,112.33 $1,279.1815736 $1,236.66 $1,174.83 $1,351.05

# 15736 $1,027.68 $976.30 $1,122.7515738 $1,307.17 $1,241.81 $1,428.08

# 15738 $1,119.05 $1,063.10 $1,222.5715740 $786.04 $746.74 $858.75

# 15740 $704.27 $669.06 $769.4215750 $785.51 $746.23 $858.1615756 $2,084.32 $1,980.10 $2,277.1215757 $2,077.94 $1,974.04 $2,270.1515758 $2,079.26 $1,975.30 $2,271.6015760 $698.33 $663.41 $762.92

# 15760 $601.07 $571.02 $656.6715770 $557.31 $529.44 $608.8615775 $288.17 $273.76 $314.82

# 15775 $199.33 $189.36 $217.7615776 $380.29 $361.28 $415.47

# 15776 $296.49 $281.67 $323.9215780 $702.26 $667.15 $767.22

# 15780 $578.41 $549.49 $631.9115781 $426.20 $404.89 $465.62

# 15781 $361.92 $343.82 $395.3915782 $489.70 $465.22 $535.00

# 15782 $372.25 $353.64 $406.6915783 $398.72 $378.78 $435.60

# 15783 $305.51 $290.23 $333.7615786 $190.18 $180.67 $207.77

# 15786 $117.49 $111.62 $128.3615787 $47.37 $45.00 $51.75

# 15787 $17.75 $16.86 $19.3915788 $316.21 $300.40 $345.46

# 15788 $183.95 $174.75 $200.9615789 $456.19 $433.38 $498.39

# 15789 $343.79 $326.60 $375.5915792 $304.20 $288.99 $332.34

# 15792 $209.30 $198.84 $228.6715793 $341.99 $324.89 $373.62

# 15793 $275.02 $261.27 $300.4615819 $627.19 $595.83 $685.2015820 $451.88 $429.29 $493.68

# 15820 $406.11 $385.80 $443.6715821 $484.65 $460.42 $529.48

# 15821 $432.15 $410.54 $472.1215822 $358.70 $340.77 $391.89

# 15822 $315.29 $299.53 $344.4615823 $555.82 $528.03 $607.23

# 15823 $509.04 $483.59 $556.1315830 $1,015.33 $964.56 $1,109.2415832 $767.97 $729.57 $839.0115833 $715.91 $680.11 $782.1315834 $721.99 $685.89 $788.7715835 $746.29 $708.98 $815.3315836 $630.61 $599.08 $688.9415837 $648.58 $616.15 $708.57

# 15837 $593.73 $564.04 $648.6515838 $489.33 $464.86 $534.5915839 $694.24 $659.53 $758.46

# 15839 $606.41 $576.09 $662.5015840 $872.72 $829.08 $953.4415841 $1,451.51 $1,378.93 $1,585.7715842 $2,311.64 $2,196.06 $2,525.4715845 $815.27 $774.51 $890.6915851 $84.69 $80.46 $92.53

# 15851 $40.94 $38.89 $44.7215852 $42.61 $40.48 $46.5515860 $100.90 $95.86 $110.2415920 $501.94 $476.84 $548.3715922 $637.98 $606.08 $696.9915931 $571.39 $542.82 $624.2415933 $706.44 $671.12 $771.7915934 $789.17 $749.71 $862.1715935 $948.61 $901.18 $1,036.3615936 $775.15 $736.39 $846.8515937 $905.02 $859.77 $988.7415940 $593.80 $564.11 $648.7315941 $783.90 $744.71 $856.4215944 $761.49 $723.42 $831.9315945 $846.11 $803.80 $924.3715946 $1,399.69 $1,329.71 $1,529.1715950 $486.53 $462.20 $531.5315951 $705.05 $669.80 $770.2715952 $729.36 $692.89 $796.8215953 $821.21 $780.15 $897.1715956 $993.83 $944.14 $1,085.7615958 $1,006.48 $956.16 $1,099.5816000 $60.92 $57.87 $66.55

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

# 16000 $41.74 $39.65 $45.6016020 $72.02 $68.42 $78.68

# 16020 $49.47 $47.00 $54.0516025 $127.13 $120.77 $138.89

# 16025 $100.88 $95.84 $110.2216030 $150.22 $142.71 $164.12

# 16030 $115.22 $109.46 $125.8816035 $193.49 $183.82 $211.3916036 $77.01 $73.16 $84.1317000 $58.57 $55.64 $63.99

# 17000 $42.08 $39.98 $45.9817003 $6.31 $5.99 $6.89

# 17003 $4.63 $4.40 $5.0617004 $144.23 $137.02 $157.57

# 17004 $117.65 $111.77 $128.5417106 $325.14 $308.88 $355.21

# 17106 $281.39 $267.32 $307.4217107 $578.07 $549.17 $631.55

# 17107 $516.49 $490.67 $564.2717108 $782.93 $743.78 $855.35

# 17108 $720.67 $684.64 $787.3417110 $80.27 $76.26 $87.70

# 17110 $49.31 $46.84 $53.8717111 $95.47 $90.70 $104.31

# 17111 $63.83 $60.64 $69.7417250 $61.12 $58.06 $66.77

# 17250 $30.83 $29.29 $33.6817260 $77.59 $73.71 $84.77

# 17260 $56.39 $53.57 $61.6117261 $104.14 $98.93 $113.77

# 17261 $72.51 $68.88 $79.2117262 $128.25 $121.84 $140.12

# 17262 $93.26 $88.60 $101.8917263 $141.85 $134.76 $154.97

# 17263 $103.48 $98.31 $113.0617264 $153.16 $145.50 $167.33

# 17264 $110.09 $104.59 $120.2817266 $176.56 $167.73 $192.89

# 17266 $128.10 $121.70 $139.9617270 $111.13 $105.57 $121.41

# 17270 $78.82 $74.88 $86.1117271 $120.85 $114.81 $132.03

# 17271 $88.88 $84.44 $97.1117272 $138.73 $131.79 $151.56

# 17272 $103.06 $97.91 $112.6017273 $155.94 $148.14 $170.36

# 17273 $116.57 $110.74 $127.3517274 $187.97 $178.57 $205.36

# 17274 $143.88 $136.69 $157.19

17276 $222.59 $211.46 $243.18# 17276 $174.80 $166.06 $190.97

17280 $102.79 $97.65 $112.30# 17280 $71.50 $67.93 $78.12

17281 $132.80 $126.16 $145.08# 17281 $100.49 $95.47 $109.79

17282 $153.88 $146.19 $168.12# 17282 $116.86 $111.02 $127.67

17283 $188.81 $179.37 $206.28# 17283 $147.08 $139.73 $160.69

17284 $222.31 $211.19 $242.87# 17284 $176.54 $167.71 $192.87

17286 $289.50 $275.03 $316.28# 17286 $242.05 $229.95 $264.44

17311 $582.59 $553.46 $636.48# 17311 $325.82 $309.53 $355.96

17312 $349.77 $332.28 $382.12# 17312 $173.43 $164.76 $189.47

17313 $531.67 $505.09 $580.85# 17313 $292.06 $277.46 $319.08

17314 $323.94 $307.74 $353.90# 17314 $160.38 $152.36 $175.21

17315 $69.26 $65.80 $75.67# 17315 $45.37 $43.10 $49.57

17340 $39.55 $37.57 $43.2117360 $103.09 $97.94 $112.63

# 17360 $81.89 $77.80 $89.4719000 $96.76 $91.92 $105.71

# 19000 $41.23 $39.17 $45.0519001 $24.15 $22.94 $26.38

# 19001 $20.45 $19.43 $22.3419020 $357.39 $339.52 $390.45

# 19020 $235.23 $223.47 $256.9919030 $148.18 $140.77 $161.89

# 19030 $71.45 $67.88 $78.0619100 $118.20 $112.29 $129.13

# 19100 $62.00 $58.90 $67.7419101 $271.91 $258.31 $297.06

# 19101 $185.08 $175.83 $202.2019102 $196.73 $186.89 $214.92

# 19102 $94.42 $89.70 $103.1619103 $506.34 $481.02 $553.17

# 19103 $175.54 $166.76 $191.7719105 $1,681.51 $1,597.43 $1,837.04

# 19105 $169.48 $161.01 $185.1619110 $366.75 $348.41 $400.67

# 19110 $266.80 $253.46 $291.4819112 $348.25 $330.84 $380.47

# 19112 $237.19 $225.33 $259.13

19120 $380.47 $361.45 $415.67# 19120 $328.98 $312.53 $359.41

19125 $418.67 $397.74 $457.40# 19125 $364.82 $346.58 $398.57

19126 $144.36 $137.14 $157.7119260 $1,039.11 $987.15 $1,135.2219271 $1,419.35 $1,348.38 $1,550.6419272 $1,566.82 $1,488.48 $1,711.7519290 $140.10 $133.10 $153.07

# 19290 $59.34 $56.37 $64.8319291 $62.31 $59.19 $68.07

# 19291 $29.67 $28.19 $32.4219295 $86.82 $82.48 $94.85

# 19295 $68.31 $64.89 $74.6219296 $4,002.95 $3,802.80 $4,373.22

# 19296 $184.35 $175.13 $201.4019297 $84.60 $80.37 $92.4319298 $1,477.27 $1,403.41 $1,613.92

# 19298 $298.41 $283.49 $326.0119300 $447.38 $425.01 $488.76

# 19300 $318.16 $302.25 $347.5919301 $348.53 $331.10 $380.7719302 $744.67 $707.44 $813.5619303 $759.09 $721.14 $829.3119304 $462.26 $439.15 $505.0219305 $921.34 $875.27 $1,006.5619306 $957.95 $910.05 $1,046.5619307 $963.37 $915.20 $1,052.4819316 $679.84 $645.85 $742.7319318 $1,008.19 $957.78 $1,101.4519324 $417.52 $396.64 $456.1419325 $555.08 $527.33 $606.4319328 $416.69 $395.86 $455.2419330 $533.77 $507.08 $583.1419340 $353.92 $336.22 $386.6519342 $786.80 $747.46 $859.5819350 $787.74 $748.35 $860.60

# 19350 $591.54 $561.96 $646.2519355 $640.80 $608.76 $700.07

# 19355 $476.91 $453.06 $521.0219357 $1,327.17 $1,260.81 $1,449.9319361 $1,346.86 $1,279.52 $1,471.4519364 $2,445.66 $2,323.38 $2,671.8919366 $1,227.08 $1,165.73 $1,340.5919367 $1,595.17 $1,515.41 $1,742.7219368 $1,966.10 $1,867.80 $2,147.9719369 $1,810.14 $1,719.63 $1,977.5719370 $582.83 $553.69 $636.7419371 $673.30 $639.64 $735.59

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

19380 $656.40 $623.58 $717.1219396 $149.53 $142.05 $163.36

# 19396 $119.58 $113.60 $130.6420000 $172.30 $163.69 $188.24

# 20000 $137.64 $130.76 $150.3720005 $255.37 $242.60 $278.99

# 20005 $210.27 $199.76 $229.7220100 $535.78 $508.99 $585.3420101 $327.50 $311.13 $357.80

# 20101 $178.08 $169.18 $194.5620102 $397.22 $377.36 $433.96

# 20102 $214.48 $203.76 $234.3220103 $487.50 $463.13 $532.60

# 20103 $314.86 $299.12 $343.9920150 $808.94 $768.49 $883.7620200 $160.29 $152.28 $175.12

# 20200 $82.22 $78.11 $89.8320205 $221.21 $210.15 $241.67

# 20205 $130.34 $123.82 $142.3920206 $242.02 $229.92 $264.41

# 20206 $56.26 $53.45 $61.4720220 $182.84 $173.70 $199.76

# 20220 $71.11 $67.55 $77.6820225 $794.21 $754.50 $867.68

# 20225 $108.02 $102.62 $118.0120240 $207.45 $197.08 $226.6420245 $557.41 $529.54 $608.9720250 $329.67 $313.19 $360.1720251 $370.36 $351.84 $404.6220500 $114.09 $108.39 $124.65

# 20500 $92.22 $87.61 $100.7520501 $119.31 $113.34 $130.34

# 20501 $35.18 $33.42 $38.4320520 $165.91 $157.61 $181.25

# 20520 $127.21 $120.85 $138.9820525 $426.85 $405.51 $466.34

# 20525 $221.57 $210.49 $242.0620526 $67.85 $64.46 $74.13

# 20526 $53.37 $50.70 $58.3120550 $51.61 $49.03 $56.38

# 20550 $36.81 $34.97 $40.2220551 $50.61 $48.08 $55.29

# 20551 $38.83 $36.89 $42.4220552 $47.25 $44.89 $51.62

# 20552 $31.09 $29.54 $33.9720553 $52.97 $50.32 $57.87

# 20553 $34.47 $32.75 $37.6620600 $47.24 $44.88 $51.61

# 20600 $36.47 $34.65 $39.85

20605 $51.36 $48.79 $56.11# 20605 $37.56 $35.68 $41.03

20610 $63.56 $60.38 $69.44# 20610 $44.71 $42.47 $48.84

20612 $51.10 $48.55 $55.83# 20612 $38.99 $37.04 $42.60

20615 $196.51 $186.68 $214.68# 20615 $143.34 $136.17 $156.60

20650 $167.66 $159.28 $183.17# 20650 $138.72 $131.78 $151.55

20660 $211.00 $200.45 $230.52# 20660 $158.83 $150.89 $173.52

20661 $387.76 $368.37 $423.6320662 $412.42 $391.80 $450.5720663 $388.30 $368.89 $424.2220664 $641.19 $609.13 $700.5020665 $118.45 $112.53 $129.41

# 20665 $94.55 $89.82 $103.2920670 $416.51 $395.68 $455.03

# 20670 $136.52 $129.69 $149.1420680 $510.34 $484.82 $557.54

# 20680 $348.47 $331.05 $380.7120690 $227.52 $216.14 $248.5620692 $376.14 $357.33 $410.9320693 $411.86 $391.27 $449.9620694 $392.07 $372.47 $428.34

# 20694 $298.85 $283.91 $326.5020802 $2,306.35 $2,191.03 $2,519.6820805 $2,990.68 $2,841.15 $3,267.3220808 $3,769.10 $3,580.65 $4,117.7520816 $2,394.08 $2,274.38 $2,615.5420822 $2,102.94 $1,997.79 $2,297.4620824 $2,376.55 $2,257.72 $2,596.3820827 $2,174.22 $2,065.51 $2,375.3420838 $2,164.16 $2,055.95 $2,364.3420900 $519.14 $493.18 $567.16

# 20900 $413.13 $392.47 $451.3420902 $538.58 $511.65 $588.4020910 $378.52 $359.59 $413.5320912 $427.78 $406.39 $467.3520920 $350.27 $332.76 $382.6720922 $510.49 $484.97 $557.72

# 20922 $421.65 $400.57 $460.6620924 $450.23 $427.72 $491.8820926 $380.59 $361.56 $415.7920931 $105.39 $100.12 $115.1420937 $159.24 $151.28 $173.9720938 $173.89 $165.20 $189.9820950 $257.13 $244.27 $280.91

# 20950 $81.80 $77.71 $89.3720955 $2,295.64 $2,180.86 $2,507.9920956 $2,430.06 $2,308.56 $2,654.8420957 $2,321.99 $2,205.89 $2,536.7720962 $2,405.83 $2,285.54 $2,628.3720969 $2,544.63 $2,417.40 $2,780.0120970 $2,542.87 $2,415.73 $2,778.0920972 $2,352.83 $2,235.19 $2,570.4720973 $2,548.75 $2,421.31 $2,784.5120974 $50.80 $48.26 $55.50

# 20974 $42.73 $40.59 $46.6820975 $161.55 $153.47 $176.4920979 $49.46 $46.99 $54.04

# 20979 $34.66 $32.93 $37.8720982 $3,695.39 $3,510.62 $4,037.21

# 20982 $365.76 $347.47 $399.5921010 $637.59 $605.71 $696.5721015 $377.19 $358.33 $412.0821025 $836.09 $794.29 $913.43

# 21025 $731.42 $694.85 $799.0821026 $480.66 $456.63 $525.12

# 21026 $417.72 $396.83 $456.3521029 $627.92 $596.52 $686.00

# 21029 $543.45 $516.28 $593.7221030 $402.15 $382.04 $439.35

# 21030 $348.31 $330.89 $380.5221031 $307.76 $292.37 $336.23

# 21031 $248.20 $235.79 $271.1621032 $313.24 $297.58 $342.22

# 21032 $244.58 $232.35 $267.2021034 $1,156.38 $1,098.56 $1,263.34

# 21034 $1,043.31 $991.14 $1,139.8121040 $404.17 $383.96 $441.55

# 21040 $340.57 $323.54 $372.0721044 $767.63 $729.25 $838.6421045 $1,066.24 $1,012.93 $1,164.8721046 $937.15 $890.29 $1,023.8321047 $1,169.81 $1,111.32 $1,278.0221048 $954.90 $907.16 $1,043.2321049 $1,109.88 $1,054.39 $1,212.5521050 $750.33 $712.81 $819.7321060 $699.14 $664.18 $763.8121070 $563.42 $535.25 $615.5421076 $902.30 $857.19 $985.77

# 21076 $817.15 $776.29 $892.7321077 $2,249.43 $2,136.96 $2,457.50

# 21077 $2,062.65 $1,959.52 $2,253.4521079 $1,525.59 $1,449.31 $1,666.71

# 21079 $1,370.11 $1,301.60 $1,496.84

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

21080 $1,732.76 $1,646.12 $1,893.04# 21080 $1,547.00 $1,469.65 $1,690.10

21081 $1,573.71 $1,495.02 $1,719.27# 21081 $1,400.06 $1,330.06 $1,529.57

21082 $1,428.75 $1,357.31 $1,560.91# 21082 $1,283.37 $1,219.20 $1,402.08

21083 $1,351.83 $1,284.24 $1,476.88# 21083 $1,185.25 $1,125.99 $1,294.89

21084 $1,543.34 $1,466.17 $1,686.10# 21084 $1,361.62 $1,293.54 $1,487.57

21085 $616.15 $585.34 $673.14# 21085 $550.86 $523.32 $601.82

21086 $1,680.27 $1,596.26 $1,835.70# 21086 $1,536.90 $1,460.06 $1,679.07

21087 $1,661.50 $1,578.43 $1,815.19# 21087 $1,523.52 $1,447.34 $1,664.44

21100 $573.58 $544.90 $626.64# 21100 $329.26 $312.80 $359.72

21110 $574.86 $546.12 $628.04# 21110 $516.30 $490.49 $564.06

21116 $158.89 $150.95 $173.59# 21116 $39.76 $37.77 $43.44

21120 $542.18 $515.07 $592.33# 21120 $437.86 $415.97 $478.37

21121 $627.83 $596.44 $685.91# 21121 $553.79 $526.10 $605.02

21122 $611.32 $580.75 $667.8621123 $787.14 $747.78 $859.9521125 $2,360.92 $2,242.87 $2,579.30

# 21125 $660.77 $627.73 $721.8921127 $2,282.18 $2,168.07 $2,493.28

# 21127 $773.85 $735.16 $845.4321137 $638.26 $606.35 $697.3021138 $807.28 $766.92 $881.9621139 $897.84 $852.95 $980.8921141 $1,178.34 $1,119.42 $1,287.3321142 $1,173.98 $1,115.28 $1,282.5721143 $1,197.66 $1,137.78 $1,308.4521145 $1,358.76 $1,290.82 $1,484.4421146 $1,403.86 $1,333.67 $1,533.7221147 $1,448.38 $1,375.96 $1,582.3521150 $1,496.95 $1,422.10 $1,635.4221151 $1,736.86 $1,650.02 $1,897.5221154 $1,908.47 $1,813.05 $2,085.0121155 $2,129.15 $2,022.69 $2,326.0921159 $2,596.73 $2,466.89 $2,836.9221160 $2,634.99 $2,503.24 $2,878.7321172 $1,539.38 $1,462.41 $1,681.7721175 $1,860.98 $1,767.93 $2,033.12

21179 $1,312.13 $1,246.52 $1,433.5021180 $1,479.95 $1,405.95 $1,616.8421181 $639.19 $607.23 $698.3121182 $1,803.34 $1,713.17 $1,970.1521183 $2,018.65 $1,917.72 $2,205.3821184 $2,236.74 $2,124.90 $2,443.6421188 $1,441.71 $1,369.62 $1,575.0621193 $1,113.07 $1,057.42 $1,216.0321194 $1,245.32 $1,183.05 $1,360.5121195 $1,185.49 $1,126.22 $1,295.1521196 $1,278.55 $1,214.62 $1,396.8121198 $990.50 $940.98 $1,082.1321199 $901.33 $856.26 $984.7021206 $981.31 $932.24 $1,072.0821208 $1,252.74 $1,190.10 $1,368.62

# 21208 $724.05 $687.85 $791.0321209 $665.39 $632.12 $726.94

# 21209 $555.34 $527.57 $606.7121210 $1,427.26 $1,355.90 $1,559.29

# 21210 $733.67 $696.99 $801.5421215 $2,239.97 $2,127.97 $2,447.17

# 21215 $762.60 $724.47 $833.1421230 $681.59 $647.51 $744.6421235 $600.81 $570.77 $656.39

# 21235 $482.02 $457.92 $526.6121240 $997.75 $947.86 $1,090.0421242 $913.62 $867.94 $998.1321243 $1,487.00 $1,412.65 $1,624.5521244 $895.29 $850.53 $978.1121245 $955.40 $907.63 $1,043.77

# 21245 $795.55 $755.77 $869.1421246 $765.84 $727.55 $836.6821247 $1,454.23 $1,381.52 $1,588.7521248 $891.76 $847.17 $974.25

# 21248 $780.37 $741.35 $852.5521249 $1,274.57 $1,210.84 $1,392.47

# 21249 $1,121.11 $1,065.05 $1,224.8121255 $1,219.14 $1,158.18 $1,331.9121256 $1,026.18 $974.87 $1,121.1021260 $1,038.34 $986.42 $1,134.3821261 $2,001.03 $1,900.98 $2,186.1321263 $1,733.84 $1,647.15 $1,894.2221267 $1,390.34 $1,320.82 $1,518.9421268 $1,680.14 $1,596.13 $1,835.5521270 $771.21 $732.65 $842.55

# 21270 $616.07 $585.27 $673.0621275 $710.08 $674.58 $775.7721280 $448.96 $426.51 $490.4921282 $298.31 $283.39 $325.90

21295 $153.30 $145.64 $167.4921296 $340.79 $323.75 $372.3121310 $95.41 $90.64 $104.24

# 21310 $26.09 $24.79 $28.5121315 $209.68 $199.20 $229.08

# 21315 $126.89 $120.55 $138.6321320 $202.22 $192.11 $220.93

# 21320 $120.78 $114.74 $131.9521325 $423.65 $402.47 $462.8421330 $520.59 $494.56 $568.7421335 $637.17 $605.31 $696.1121336 $553.90 $526.21 $605.1421337 $324.65 $308.42 $354.68

# 21337 $239.17 $227.21 $261.2921338 $693.57 $658.89 $757.7221339 $760.01 $722.01 $830.3121340 $697.12 $662.26 $761.6021343 $1,027.00 $975.65 $1,122.0021344 $1,338.41 $1,271.49 $1,462.2121345 $663.58 $630.40 $724.96

# 21345 $565.31 $537.04 $617.6021346 $824.47 $783.25 $900.7421347 $1,012.04 $961.44 $1,105.6621348 $1,008.12 $957.71 $1,101.3721355 $363.37 $345.20 $396.98

# 21355 $272.17 $258.56 $297.3421356 $412.90 $392.26 $451.10

# 21356 $324.06 $307.86 $354.0421360 $459.04 $436.09 $501.5021365 $969.84 $921.35 $1,059.5521366 $1,085.60 $1,031.32 $1,186.0221385 $622.73 $591.59 $680.3321386 $582.69 $553.56 $636.5921387 $664.79 $631.55 $726.2821390 $664.58 $631.35 $726.0521395 $841.18 $799.12 $918.9921400 $143.11 $135.95 $156.34

# 21400 $118.21 $112.30 $129.1521401 $396.82 $376.98 $433.53

# 21401 $249.08 $236.63 $272.1221406 $470.20 $446.69 $513.6921407 $558.36 $530.44 $610.0121408 $772.16 $733.55 $843.5821421 $559.71 $531.72 $611.48

# 21421 $507.88 $482.49 $554.8621422 $588.54 $559.11 $642.9821423 $704.80 $669.56 $769.9921431 $606.48 $576.16 $662.5821432 $590.16 $560.65 $644.75

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

21433 $1,503.24 $1,428.08 $1,642.2921435 $1,159.80 $1,101.81 $1,267.0821436 $1,707.76 $1,622.37 $1,865.7321440 $390.33 $370.81 $426.43

# 21440 $344.22 $327.01 $376.0621445 $583.13 $553.97 $637.07

# 21445 $515.83 $490.04 $563.5521450 $405.50 $385.23 $443.01

# 21450 $369.83 $351.34 $404.0421451 $552.03 $524.43 $603.09

# 21451 $500.20 $475.19 $546.4721452 $514.47 $488.75 $562.06

# 21452 $252.98 $240.33 $276.3821453 $638.39 $606.47 $697.44

# 21453 $611.81 $581.22 $668.4021454 $478.42 $454.50 $522.6821461 $1,305.75 $1,240.46 $1,426.53

# 21461 $767.97 $729.57 $839.0121462 $1,462.92 $1,389.77 $1,598.24

# 21462 $842.02 $799.92 $919.9121465 $807.23 $766.87 $881.9021470 $1,043.19 $991.03 $1,139.6821480 $80.05 $76.05 $87.46

# 21480 $29.24 $27.78 $31.9521485 $483.09 $458.94 $527.78

# 21485 $443.72 $421.53 $484.7621490 $810.49 $769.97 $885.4721495 $532.35 $505.73 $581.5921497 $482.25 $458.14 $526.86

# 21497 $438.50 $416.58 $479.0721501 $361.94 $343.84 $395.42

# 21501 $271.75 $258.16 $296.8821502 $467.90 $444.51 $511.1921510 $415.96 $395.16 $454.4321550 $202.40 $192.28 $221.12

# 21550 $134.09 $127.39 $146.5021555 $356.20 $338.39 $389.15

# 21555 $278.12 $264.21 $303.8421556 $350.74 $333.20 $383.1821557 $512.22 $486.61 $559.6021600 $469.82 $446.33 $513.2821610 $932.51 $885.88 $1,018.7621615 $614.37 $583.65 $671.2021616 $752.34 $714.72 $821.9321620 $468.56 $445.13 $511.9021627 $485.46 $461.19 $530.3721630 $1,123.79 $1,067.60 $1,227.7421632 $1,114.91 $1,059.16 $1,218.0321685 $861.83 $818.74 $941.55

21700 $368.95 $350.50 $403.0821705 $563.08 $534.93 $615.1721720 $324.08 $307.88 $354.0621725 $458.52 $435.59 $500.9321740 $963.82 $915.63 $1,052.9721750 $641.19 $609.13 $700.5021800 $81.45 $77.38 $88.9921805 $218.56 $207.63 $238.7721810 $436.35 $414.53 $476.7121820 $111.30 $105.74 $121.60

# 21820 $109.62 $104.14 $119.7621825 $505.06 $479.81 $551.7821920 $195.68 $185.90 $213.79

# 21920 $128.71 $122.27 $140.6121925 $350.97 $333.42 $383.43

# 21925 $285.35 $271.08 $311.7421930 $389.30 $369.84 $425.32

# 21930 $311.89 $296.30 $340.7521935 $1,024.48 $973.26 $1,119.2522010 $777.07 $738.22 $848.9522015 $770.60 $732.07 $841.8822100 $697.47 $662.60 $761.9922101 $697.88 $662.99 $762.4422102 $699.57 $664.59 $764.2822103 $132.29 $125.68 $144.5322110 $870.95 $827.40 $951.5122112 $866.90 $823.56 $947.0922114 $870.91 $827.36 $951.4622116 $132.90 $126.26 $145.2022210 $1,552.45 $1,474.83 $1,696.0522212 $1,277.70 $1,213.82 $1,395.8922214 $1,293.98 $1,229.28 $1,413.6722216 $347.70 $330.32 $379.8722220 $1,400.92 $1,330.87 $1,530.5022222 $1,300.47 $1,235.45 $1,420.7722224 $1,388.62 $1,319.19 $1,517.0722226 $344.67 $327.44 $376.5622305 $160.27 $152.26 $175.10

# 22305 $147.48 $140.11 $161.1322310 $238.41 $226.49 $260.46

# 22310 $223.26 $212.10 $243.9222315 $726.80 $690.46 $794.03

# 22315 $647.38 $615.01 $707.2622318 $1,395.55 $1,325.77 $1,524.6422319 $1,549.67 $1,472.19 $1,693.0222325 $1,204.82 $1,144.58 $1,316.2722326 $1,274.81 $1,211.07 $1,392.7322327 $1,248.60 $1,186.17 $1,364.1022328 $260.60 $247.57 $284.71

22505 $108.32 $102.90 $118.3422520 $2,282.51 $2,168.38 $2,493.64

# 22520 $532.90 $506.26 $582.2022521 $2,125.54 $2,019.26 $2,322.15

# 22521 $504.14 $478.93 $550.7722522 $227.52 $216.14 $248.5622523 $559.61 $531.63 $611.3722524 $535.23 $508.47 $584.7422525 $251.04 $238.49 $274.2622526 $1,810.81 $1,720.27 $1,978.31

# 22526 $315.60 $299.82 $344.7922527 $1,465.22 $1,391.96 $1,600.75

# 22527 $146.36 $139.04 $159.9022532 $1,516.01 $1,440.21 $1,656.2422533 $1,400.73 $1,330.69 $1,530.2922534 $342.20 $325.09 $373.8522548 $1,630.37 $1,548.85 $1,781.1822554 $1,149.59 $1,092.11 $1,255.9322556 $1,462.92 $1,389.77 $1,598.2422558 $1,333.25 $1,266.59 $1,456.5822585 $317.83 $301.94 $347.2322590 $1,342.16 $1,275.05 $1,466.3122595 $1,274.72 $1,210.98 $1,392.6322600 $1,088.93 $1,034.48 $1,189.6522610 $1,080.11 $1,026.10 $1,180.0222612 $1,411.48 $1,340.91 $1,542.0522614 $371.08 $352.53 $405.4122630 $1,354.56 $1,286.83 $1,479.8522632 $300.89 $285.85 $328.7322800 $1,199.92 $1,139.92 $1,310.9122802 $1,924.76 $1,828.52 $2,102.8022804 $2,231.81 $2,120.22 $2,438.2522808 $1,623.87 $1,542.68 $1,774.0822810 $1,828.17 $1,736.76 $1,997.2722812 $1,984.15 $1,884.94 $2,167.6822818 $1,997.94 $1,898.04 $2,182.7522819 $2,262.34 $2,149.22 $2,471.6022830 $717.21 $681.35 $783.5522840 $725.05 $688.80 $792.1222842 $725.57 $689.29 $792.6822843 $764.90 $726.66 $835.6622844 $942.09 $894.99 $1,029.2422845 $694.56 $659.83 $758.8022846 $721.51 $685.43 $788.2422847 $792.38 $752.76 $865.6722848 $342.91 $325.76 $374.6222849 $1,163.69 $1,105.51 $1,271.3422850 $631.88 $600.29 $690.3322851 $385.23 $365.97 $420.87

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

22852 $604.32 $574.10 $660.2222855 $977.51 $928.63 $1,067.9222857 $1,332.75 $1,266.11 $1,456.0322862 $1,623.11 $1,541.95 $1,773.2422865 $1,580.44 $1,501.42 $1,726.6322900 $345.59 $328.31 $377.5623000 $453.42 $430.75 $495.36

# 23000 $315.44 $299.67 $344.6223020 $611.95 $581.35 $668.5523030 $375.39 $356.62 $410.11

# 23030 $229.67 $218.19 $250.9223031 $362.06 $343.96 $395.55

# 23031 $196.82 $186.98 $215.0323035 $625.01 $593.76 $682.8223040 $637.31 $605.44 $696.2623044 $505.73 $480.44 $552.5123065 $171.86 $163.27 $187.76

# 23065 $139.89 $132.90 $152.8423066 $422.42 $401.30 $461.50

# 23066 $295.22 $280.46 $322.5323075 $217.08 $206.23 $237.16

# 23075 $153.14 $145.48 $167.3023076 $487.68 $463.30 $532.8023077 $1,034.82 $983.08 $1,130.5423100 $428.46 $407.04 $468.1023101 $396.75 $376.91 $433.4523105 $563.88 $535.69 $616.0423106 $420.78 $399.74 $459.7023107 $587.55 $558.17 $641.9023120 $496.68 $471.85 $542.6323125 $623.09 $591.94 $680.7323130 $534.86 $508.12 $584.3423140 $447.08 $424.73 $488.4423145 $603.05 $572.90 $658.8423146 $546.22 $518.91 $596.7523150 $569.60 $541.12 $622.2923155 $697.95 $663.05 $762.5123156 $597.23 $567.37 $652.4823170 $474.37 $450.65 $518.2523172 $480.17 $456.16 $524.5823174 $664.90 $631.66 $726.4123180 $637.41 $605.54 $696.3723182 $608.40 $577.98 $664.6823184 $685.60 $651.32 $749.0223190 $491.48 $466.91 $536.9523195 $658.46 $625.54 $719.3723200 $780.47 $741.45 $852.6723210 $812.89 $772.25 $888.0923220 $956.40 $908.58 $1,044.87

23221 $1,080.97 $1,026.92 $1,180.9623222 $1,512.03 $1,436.43 $1,651.8923330 $192.82 $183.18 $210.66

# 23330 $132.25 $125.64 $144.4923331 $519.26 $493.30 $567.3023332 $787.79 $748.40 $860.6623350 $144.81 $137.57 $158.21

# 23350 $46.88 $44.54 $51.2223395 $1,141.45 $1,084.38 $1,247.0423397 $1,027.12 $975.76 $1,122.1223400 $871.17 $827.61 $951.7523405 $560.76 $532.72 $612.6323406 $703.32 $668.15 $768.3723410 $806.43 $766.11 $881.0323412 $858.71 $815.77 $938.1423415 $659.20 $626.24 $720.1823420 $936.66 $889.83 $1,023.3023430 $662.44 $629.32 $723.7223440 $686.11 $651.80 $749.5723450 $858.12 $815.21 $937.4923455 $915.65 $869.87 $1,000.3523460 $989.54 $940.06 $1,081.0723462 $966.72 $918.38 $1,056.1423465 $1,006.48 $956.16 $1,099.5823466 $984.76 $935.52 $1,075.8523470 $1,099.98 $1,044.98 $1,201.7323472 $1,355.74 $1,287.95 $1,481.1423480 $737.93 $701.03 $806.1823485 $868.01 $824.61 $948.3023490 $734.06 $697.36 $801.9623491 $918.76 $872.82 $1,003.7423500 $177.33 $168.46 $193.73

# 23500 $168.58 $160.15 $184.1723505 $292.72 $278.08 $319.79

# 23505 $275.22 $261.46 $300.6823515 $510.05 $484.55 $557.2323520 $180.98 $171.93 $197.72

# 23520 $178.29 $169.38 $194.7923525 $292.85 $278.21 $319.94

# 23525 $273.00 $259.35 $298.2523530 $485.46 $461.19 $530.3723532 $548.70 $521.27 $599.4623540 $181.59 $172.51 $198.39

# 23540 $169.14 $160.68 $184.7823545 $262.29 $249.18 $286.56

# 23545 $237.39 $225.52 $259.3523550 $504.04 $478.84 $550.6723552 $582.64 $553.51 $636.5423570 $189.31 $179.84 $206.82

# 23570 $186.28 $176.97 $203.5223575 $320.13 $304.12 $349.74

# 23575 $301.62 $286.54 $329.5223585 $611.28 $580.72 $667.8323600 $267.41 $254.04 $292.15

# 23600 $238.81 $226.87 $260.9023605 $397.19 $377.33 $433.93

# 23605 $364.21 $346.00 $397.9023615 $719.68 $683.70 $786.2623616 $1,317.05 $1,251.20 $1,438.8823620 $216.90 $206.06 $236.97

# 23620 $198.73 $188.79 $217.1123625 $320.60 $304.57 $350.26

# 23625 $299.40 $284.43 $327.0923630 $512.40 $486.78 $559.8023650 $249.94 $237.44 $273.06

# 23650 $220.33 $209.31 $240.7123655 $321.38 $305.31 $351.1123660 $508.99 $483.54 $556.0723665 $353.63 $335.95 $386.34

# 23665 $333.44 $316.77 $364.2923670 $540.71 $513.67 $590.7223675 $466.63 $443.30 $509.80

# 23675 $433.31 $411.64 $473.3923680 $673.47 $639.80 $735.7723700 $172.09 $163.49 $188.0123800 $903.03 $857.88 $986.5623802 $1,059.61 $1,006.63 $1,157.6223900 $1,193.49 $1,133.82 $1,303.8923920 $960.00 $912.00 $1,048.8023921 $386.67 $367.34 $422.4423930 $316.39 $300.57 $345.66

# 23930 $190.19 $180.68 $207.7823931 $256.54 $243.71 $280.27

# 23931 $140.77 $133.73 $153.7923935 $441.25 $419.19 $482.0724000 $413.63 $392.95 $451.8924006 $629.90 $598.41 $688.1724065 $193.40 $183.73 $211.29

# 24065 $137.53 $130.65 $150.2524066 $500.74 $475.70 $547.06

# 24066 $343.24 $326.08 $374.9924075 $399.26 $379.30 $436.20

# 24075 $267.00 $253.65 $291.7024076 $409.99 $389.49 $447.9124077 $719.51 $683.53 $786.0624100 $348.22 $330.81 $380.4324101 $437.93 $416.03 $478.4324102 $544.59 $517.36 $594.96

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

24105 $290.11 $275.60 $316.9424110 $513.03 $487.38 $560.4924115 $636.34 $604.52 $695.2024116 $775.19 $736.43 $846.8924120 $458.71 $435.77 $501.1424125 $514.88 $489.14 $562.5124126 $558.07 $530.17 $609.7024130 $445.13 $422.87 $486.3024134 $685.53 $651.25 $748.9424136 $558.92 $530.97 $610.6224138 $581.61 $552.53 $635.4124140 $662.49 $629.37 $723.7824145 $561.09 $533.04 $613.0024147 $580.89 $551.85 $634.6324149 $1,006.39 $956.07 $1,099.4824150 $869.02 $825.57 $949.4124151 $1,007.92 $957.52 $1,101.1524152 $647.09 $614.74 $706.9524153 $606.22 $575.91 $662.3024155 $748.81 $711.37 $818.0824160 $535.55 $508.77 $585.0924164 $437.48 $415.61 $477.9524200 $176.68 $167.85 $193.03

# 24200 $120.14 $114.13 $131.2524201 $494.93 $470.18 $540.71

# 24201 $319.26 $303.30 $348.8024220 $160.12 $152.11 $174.93

# 24220 $61.86 $58.77 $67.5924300 $340.97 $323.92 $372.5124301 $669.67 $636.19 $731.6224305 $511.56 $485.98 $558.8824310 $418.81 $397.87 $457.5524320 $674.50 $640.78 $736.9024330 $638.16 $606.25 $697.1924331 $702.76 $667.62 $767.7624332 $525.68 $499.40 $574.3124340 $543.52 $516.34 $593.7924341 $623.79 $592.60 $681.4924342 $703.40 $668.23 $768.4624343 $619.47 $588.50 $676.7824344 $965.04 $916.79 $1,054.3124345 $616.10 $585.30 $673.1024346 $959.33 $911.36 $1,048.0624350 $392.23 $372.62 $428.5124351 $429.35 $407.88 $469.0624352 $458.24 $435.33 $500.6324354 $458.08 $435.18 $500.4624356 $470.95 $447.40 $514.5124360 $802.38 $762.26 $876.60

24361 $900.84 $855.80 $984.1724362 $936.50 $889.68 $1,023.1324363 $1,316.57 $1,250.74 $1,438.3524365 $568.81 $540.37 $621.4324366 $609.65 $579.17 $666.0524400 $733.35 $696.68 $801.1824410 $935.36 $888.59 $1,021.8824420 $876.34 $832.52 $957.4024430 $911.96 $866.36 $996.3124435 $936.63 $889.80 $1,023.2724470 $598.54 $568.61 $653.9024495 $599.07 $569.12 $654.4924498 $782.81 $743.67 $855.2224500 $288.70 $274.27 $315.41

# 24500 $253.70 $241.02 $277.1724505 $424.61 $403.38 $463.89

# 24505 $385.91 $366.61 $421.6024515 $781.09 $742.04 $853.3524516 $774.40 $735.68 $846.0324530 $311.62 $296.04 $340.45

# 24530 $276.28 $262.47 $301.8424535 $532.02 $505.42 $581.23

# 24535 $493.32 $468.65 $538.9524538 $663.55 $630.37 $724.9324545 $706.65 $671.32 $772.0224546 $1,002.49 $952.37 $1,095.2324560 $259.51 $246.53 $283.51

# 24560 $221.49 $210.42 $241.9824565 $439.21 $417.25 $479.84

# 24565 $404.55 $384.32 $441.9724566 $610.25 $579.74 $666.7024575 $711.53 $675.95 $777.3424576 $272.89 $259.25 $298.14

# 24576 $240.58 $228.55 $262.8324577 $457.26 $434.40 $499.56

# 24577 $421.92 $400.82 $460.9424579 $764.89 $726.65 $835.6524582 $685.82 $651.53 $749.2624586 $984.37 $935.15 $1,075.4224587 $975.37 $926.60 $1,065.5924600 $317.72 $301.83 $347.10

# 24600 $278.68 $264.75 $304.4624605 $394.29 $374.58 $430.7724615 $637.65 $605.77 $696.6424620 $480.65 $456.62 $525.1124635 $979.57 $930.59 $1,070.1824640 $104.58 $99.35 $114.25

# 24640 $72.61 $68.98 $79.3324650 $211.65 $201.07 $231.23

# 24650 $182.03 $172.93 $198.8724655 $369.91 $351.41 $404.12

# 24655 $334.24 $317.53 $365.1624665 $571.74 $543.15 $624.6224666 $648.84 $616.40 $708.8624670 $237.64 $225.76 $259.62

# 24670 $206.34 $196.02 $225.4224675 $386.55 $367.22 $422.30

# 24675 $353.91 $336.21 $386.6424685 $599.29 $569.33 $654.7324800 $724.02 $687.82 $790.9924802 $897.08 $852.23 $980.0624900 $626.12 $594.81 $684.0324920 $625.00 $593.75 $682.8124925 $478.40 $454.48 $522.6524930 $653.90 $621.21 $714.3924931 $732.76 $696.12 $800.5424935 $904.25 $859.04 $987.9025000 $351.50 $333.93 $384.0225001 $283.11 $268.95 $309.2925020 $534.04 $507.34 $583.4425023 $1,008.72 $958.28 $1,102.0225024 $656.98 $624.13 $717.7525025 $995.09 $945.34 $1,087.1425028 $466.24 $442.93 $509.3725031 $409.51 $389.03 $447.3825035 $715.93 $680.13 $782.1525040 $524.97 $498.72 $573.5325065 $191.05 $181.50 $208.73

# 25065 $138.21 $131.30 $151.0025066 $387.97 $368.57 $423.8625075 $337.00 $320.15 $368.1725076 $492.92 $468.27 $538.5125077 $764.92 $726.67 $835.6725085 $443.27 $421.11 $484.2825100 $323.11 $306.95 $352.9925101 $375.92 $357.12 $410.6925105 $465.85 $442.56 $508.9425107 $560.07 $532.07 $611.8825109 $442.98 $420.83 $483.9525110 $378.04 $359.14 $413.0125111 $287.90 $273.51 $314.5425112 $350.44 $332.92 $382.8625115 $821.49 $780.42 $897.4825116 $696.87 $662.03 $761.3325118 $357.59 $339.71 $390.6725119 $481.36 $457.29 $525.8825120 $614.83 $584.09 $671.7025125 $690.45 $655.93 $754.32

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

25126 $704.44 $669.22 $769.6025130 $413.79 $393.10 $452.0725135 $512.88 $487.24 $560.3325136 $452.78 $430.14 $494.6625145 $625.61 $594.33 $683.4825150 $547.02 $519.67 $597.6225151 $690.17 $655.66 $754.0125170 $917.06 $871.21 $1,001.8925210 $452.78 $430.14 $494.6625215 $591.57 $561.99 $646.2925230 $403.23 $383.07 $440.5325240 $424.84 $403.60 $464.1425246 $160.63 $152.60 $175.49

# 25246 $68.09 $64.69 $74.3925248 $471.61 $448.03 $515.2325250 $459.91 $436.91 $502.4525251 $629.26 $597.80 $687.4725259 $339.96 $322.96 $371.4025260 $722.69 $686.56 $789.5425263 $719.37 $683.40 $785.9125265 $834.49 $792.77 $911.6925270 $608.41 $577.99 $664.6925272 $672.59 $638.96 $734.8025274 $767.55 $729.17 $838.5525275 $590.89 $561.35 $645.5525280 $674.62 $640.89 $737.0225290 $664.58 $631.35 $726.0525295 $634.41 $602.69 $693.0925300 $619.43 $588.46 $676.7325301 $592.61 $562.98 $647.4325310 $725.43 $689.16 $792.5325312 $810.60 $770.07 $885.5825315 $860.98 $817.93 $940.6225316 $996.20 $946.39 $1,088.3525320 $851.06 $808.51 $929.7925332 $753.79 $716.10 $823.5225335 $868.11 $824.70 $948.4125337 $802.74 $762.60 $876.9925350 $785.28 $746.02 $857.9225355 $866.39 $823.07 $946.5325360 $767.45 $729.08 $838.4425365 $995.45 $945.68 $1,087.5325370 $1,057.37 $1,004.50 $1,155.1825375 $1,042.59 $990.46 $1,139.0325390 $867.77 $824.38 $948.0425391 $1,072.33 $1,018.71 $1,171.5225392 $1,065.43 $1,012.16 $1,163.9825393 $1,209.08 $1,148.63 $1,320.9225394 $679.13 $645.17 $741.95

25400 $910.64 $865.11 $994.8825405 $1,120.82 $1,064.78 $1,224.5025415 $1,047.97 $995.57 $1,144.9125420 $1,232.11 $1,170.50 $1,346.0825425 $1,191.69 $1,132.11 $1,301.9325426 $1,163.97 $1,105.77 $1,271.6425430 $613.65 $582.97 $670.4225431 $703.77 $668.58 $768.8725440 $715.24 $679.48 $781.4025441 $842.78 $800.64 $920.7425442 $712.18 $676.57 $778.0625443 $681.84 $647.75 $744.9125444 $735.14 $698.38 $803.1425445 $643.22 $611.06 $702.7225446 $1,052.46 $999.84 $1,149.8225447 $712.36 $676.74 $778.2525449 $925.08 $878.83 $1,010.6525450 $634.30 $602.59 $692.9825455 $686.43 $652.11 $749.9325490 $801.51 $761.43 $875.6425491 $841.77 $799.68 $919.6325492 $973.61 $924.93 $1,063.6725500 $215.44 $204.67 $235.37

# 25500 $190.20 $180.69 $207.7925505 $425.16 $403.90 $464.49

# 25505 $389.82 $370.33 $425.8825515 $617.83 $586.94 $674.9825520 $476.20 $452.39 $520.25

# 25520 $450.97 $428.42 $492.6825525 $829.54 $788.06 $906.2725526 $958.23 $910.32 $1,046.8725530 $208.66 $198.23 $227.96

# 25530 $181.74 $172.65 $198.5525535 $406.98 $386.63 $444.62

# 25535 $382.75 $363.61 $418.1525545 $610.40 $579.88 $666.8625560 $218.43 $207.51 $238.64

# 25560 $186.80 $177.46 $204.0825565 $445.23 $422.97 $486.42

# 25565 $404.84 $384.60 $442.2925574 $532.61 $505.98 $581.8825575 $786.37 $747.05 $859.1125600 $239.99 $227.99 $262.19

# 25600 $207.35 $196.98 $226.5325605 $513.10 $487.45 $560.57

# 25605 $481.47 $457.40 $526.0125606 $601.32 $571.25 $656.9425607 $608.39 $577.97 $664.6725608 $696.81 $661.97 $761.27

25609 $889.46 $844.99 $971.7425622 $245.68 $233.40 $268.41

# 25622 $211.69 $201.11 $231.2825624 $388.96 $369.51 $424.94

# 25624 $350.93 $333.38 $383.3925628 $628.80 $597.36 $686.9625630 $252.36 $239.74 $275.70

# 25630 $216.69 $205.86 $236.7425635 $372.21 $353.60 $406.64

# 25635 $313.99 $298.29 $343.0325645 $505.39 $480.12 $552.1425650 $262.84 $249.70 $287.16

# 25650 $230.54 $219.01 $251.8625651 $404.06 $383.86 $441.4425652 $539.36 $512.39 $589.2525660 $341.02 $323.97 $372.5725670 $541.95 $514.85 $592.0825671 $450.53 $428.00 $492.2025675 $366.24 $347.93 $400.12

# 25675 $334.95 $318.20 $365.9325676 $560.49 $532.47 $612.3425680 $390.14 $370.63 $426.2225685 $647.04 $614.69 $706.8925690 $399.30 $379.34 $436.2425695 $561.68 $533.60 $613.6425800 $682.64 $648.51 $745.7925805 $783.37 $744.20 $855.8325810 $779.00 $740.05 $851.0625820 $548.26 $520.85 $598.9825825 $669.34 $635.87 $731.2525830 $867.85 $824.46 $948.1325900 $760.95 $722.90 $831.3425905 $751.58 $714.00 $821.1025907 $671.23 $637.67 $733.3225909 $747.44 $710.07 $816.5825915 $1,235.23 $1,173.47 $1,349.4925920 $604.05 $573.85 $659.9325922 $527.51 $501.13 $576.3025924 $601.53 $571.45 $657.1725927 $716.06 $680.26 $782.3025929 $494.83 $470.09 $540.6025931 $669.99 $636.49 $731.9626010 $233.05 $221.40 $254.61

# 26010 $112.90 $107.26 $123.3526011 $361.37 $343.30 $394.80

# 26011 $161.80 $153.71 $176.7726020 $369.08 $350.63 $403.2226025 $362.42 $344.30 $395.9526030 $427.41 $406.04 $466.95

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

26034 $462.31 $439.19 $505.0726035 $695.63 $660.85 $759.9826037 $499.03 $474.08 $545.1926040 $265.81 $252.52 $290.4026045 $406.14 $385.83 $443.7026055 $554.83 $527.09 $606.15

# 26055 $248.58 $236.15 $271.5726060 $226.45 $215.13 $247.4026070 $253.35 $240.68 $276.7826075 $272.22 $258.61 $297.4026080 $329.75 $313.26 $360.2526100 $278.86 $264.92 $304.6626105 $285.70 $271.42 $312.1326110 $271.92 $258.32 $297.0726115 $566.38 $538.06 $618.77

# 26115 $309.60 $294.12 $338.2426116 $415.93 $395.13 $454.4026117 $566.92 $538.57 $619.3626121 $524.39 $498.17 $572.9026123 $703.44 $668.27 $768.5126125 $257.98 $245.08 $281.8426130 $394.19 $374.48 $430.6526135 $484.48 $460.26 $529.3026140 $439.44 $417.47 $480.0926145 $446.75 $424.41 $488.0726160 $522.22 $496.11 $570.53

# 26160 $271.51 $257.93 $296.6226170 $349.36 $331.89 $381.6726180 $381.52 $362.44 $416.8126185 $443.52 $421.34 $484.5426200 $392.48 $372.86 $428.7926205 $529.89 $503.40 $578.9126210 $381.10 $362.05 $416.3626215 $483.04 $458.89 $527.7226230 $443.04 $420.89 $484.0226235 $433.08 $411.43 $473.1426236 $383.03 $363.88 $418.4626250 $501.20 $476.14 $547.5626255 $800.82 $760.78 $874.9026260 $477.05 $453.20 $521.1826261 $569.51 $541.03 $622.1826262 $398.13 $378.22 $434.9526320 $297.87 $282.98 $325.4326340 $264.65 $251.42 $289.1326350 $686.53 $652.20 $750.0326352 $773.98 $735.28 $845.5726356 $968.14 $919.73 $1,057.6926357 $820.10 $779.10 $895.9726358 $871.38 $827.81 $951.98

26370 $743.17 $706.01 $811.9126372 $855.67 $812.89 $934.8226373 $814.40 $773.68 $889.7326390 $775.80 $737.01 $847.5626392 $921.55 $875.47 $1,006.7926410 $549.03 $521.58 $599.8226412 $656.37 $623.55 $717.0826415 $672.84 $639.20 $735.0826416 $789.62 $750.14 $862.6626418 $548.70 $521.27 $599.4626420 $686.01 $651.71 $749.4726426 $647.70 $615.32 $707.6226428 $712.65 $677.02 $778.5726432 $475.38 $451.61 $519.3526433 $512.10 $486.50 $559.4826434 $598.32 $568.40 $653.6626437 $587.22 $557.86 $641.5426440 $607.72 $577.33 $663.9326442 $864.08 $820.88 $944.0126445 $570.03 $541.53 $622.7626449 $812.93 $772.28 $888.1226450 $374.42 $355.70 $409.0626455 $371.27 $352.71 $405.6226460 $360.17 $342.16 $393.4826471 $575.10 $546.35 $628.3026474 $559.43 $531.46 $611.1826476 $543.06 $515.91 $593.3026477 $547.00 $519.65 $597.6026478 $592.85 $563.21 $647.6926479 $585.23 $555.97 $639.3726480 $724.81 $688.57 $791.8626483 $804.21 $764.00 $878.6026485 $774.73 $735.99 $846.3926489 $765.05 $726.80 $835.8226490 $728.30 $691.89 $795.6726492 $803.20 $763.04 $877.5026494 $736.90 $700.06 $805.0726496 $791.62 $752.04 $864.8526497 $797.60 $757.72 $871.3826498 $1,055.24 $1,002.48 $1,152.8526499 $756.67 $718.84 $826.6726500 $589.74 $560.25 $644.2926502 $657.15 $624.29 $717.9326508 $599.69 $569.71 $655.1726510 $563.55 $535.37 $615.6826516 $660.18 $627.17 $721.2526517 $771.46 $732.89 $842.8226518 $772.53 $733.90 $843.9926520 $634.05 $602.35 $692.70

26525 $637.87 $605.98 $696.8826530 $466.01 $442.71 $509.1226531 $543.71 $516.52 $594.0026535 $333.34 $316.67 $364.1726536 $572.16 $543.55 $625.0826540 $621.49 $590.42 $678.9826541 $753.31 $715.64 $822.9926542 $639.29 $607.33 $698.4326545 $649.97 $617.47 $710.0926546 $882.77 $838.63 $964.4226548 $715.08 $679.33 $781.2326550 $1,390.23 $1,320.72 $1,518.8326551 $2,911.64 $2,766.06 $3,180.9726553 $2,460.51 $2,337.48 $2,688.1026554 $3,358.56 $3,190.63 $3,669.2226555 $1,236.74 $1,174.90 $1,351.1426556 $2,762.05 $2,623.95 $3,017.5426560 $520.54 $494.51 $568.6926561 $814.17 $773.46 $889.4826562 $1,185.26 $1,126.00 $1,294.9026565 $635.13 $603.37 $693.8826567 $639.79 $607.80 $698.9726568 $836.77 $794.93 $914.1726580 $1,180.94 $1,121.89 $1,290.1726587 $844.55 $802.32 $922.6726590 $1,164.22 $1,106.01 $1,271.9126591 $424.37 $403.15 $463.6226593 $555.73 $527.94 $607.1326596 $640.75 $608.71 $700.0226600 $218.02 $207.12 $238.19

# 26600 $190.76 $181.22 $208.4026605 $265.43 $252.16 $289.98

# 26605 $237.84 $225.95 $259.8426607 $412.76 $392.12 $450.9426608 $416.54 $395.71 $455.0726615 $386.09 $366.79 $421.8126641 $300.25 $285.24 $328.03

# 26641 $268.61 $255.18 $293.4626645 $343.97 $326.77 $375.79

# 26645 $313.34 $297.67 $342.3226650 $445.56 $423.28 $486.7726665 $509.75 $484.26 $556.9026670 $277.65 $263.77 $303.34

# 26670 $239.62 $227.64 $261.7926675 $365.40 $347.13 $399.20

# 26675 $334.44 $317.72 $365.3826676 $437.40 $415.53 $477.8626685 $479.05 $455.10 $523.3726686 $542.26 $515.15 $592.42

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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26700 $261.84 $248.75 $286.06# 26700 $236.27 $224.46 $258.13

26705 $342.15 $325.04 $373.80# 26705 $310.18 $294.67 $338.87

26706 $372.26 $353.65 $406.7026715 $408.51 $388.08 $446.2926720 $157.86 $149.97 $172.47

# 26720 $137.33 $130.46 $150.0326725 $288.07 $273.67 $314.72

# 26725 $250.38 $237.86 $273.5426727 $410.03 $389.53 $447.9626735 $419.49 $398.52 $458.3026740 $182.16 $173.05 $199.01

# 26740 $168.70 $160.27 $184.3126742 $314.91 $299.16 $344.03

# 26742 $280.92 $266.87 $306.9026746 $412.47 $391.85 $450.6326750 $147.90 $140.51 $161.59

# 26750 $136.12 $129.31 $148.7126755 $264.96 $251.71 $289.47

# 26755 $222.22 $211.11 $242.7826756 $361.08 $343.03 $394.4826765 $310.35 $294.83 $339.0526770 $224.66 $213.43 $245.44

# 26770 $195.71 $185.92 $213.8126775 $316.13 $300.32 $345.37

# 26775 $275.41 $261.64 $300.8926776 $385.51 $366.23 $421.1626785 $316.19 $300.38 $345.4426820 $735.08 $698.33 $803.0826841 $692.13 $657.52 $756.1526842 $742.31 $705.19 $810.9726843 $680.46 $646.44 $743.4126844 $761.00 $722.95 $831.3926850 $652.79 $620.15 $713.1726852 $736.12 $699.31 $804.2126860 $532.50 $505.88 $581.7626861 $97.74 $92.85 $106.7826862 $675.21 $641.45 $737.6726863 $218.29 $207.38 $238.4926910 $653.53 $620.85 $713.9826951 $549.79 $522.30 $600.6526952 $610.27 $579.76 $666.7226990 $542.76 $515.62 $592.9626991 $628.33 $596.91 $686.45

# 26991 $452.66 $430.03 $494.5326992 $862.74 $819.60 $942.5427000 $397.21 $377.35 $433.9527001 $479.50 $455.53 $523.86

27003 $512.67 $487.04 $560.1027005 $652.01 $619.41 $712.3227006 $656.52 $623.69 $717.2427025 $777.38 $738.51 $849.2927030 $849.26 $806.80 $927.8227033 $876.18 $832.37 $957.2327035 $1,024.92 $973.67 $1,119.7227036 $887.01 $842.66 $969.0627040 $281.52 $267.44 $307.56

# 27040 $173.16 $164.50 $189.1827041 $604.09 $573.89 $659.9727047 $529.09 $502.64 $578.04

# 27047 $449.00 $426.55 $490.5327048 $410.30 $389.79 $448.2627049 $868.43 $825.01 $948.7627050 $321.78 $305.69 $351.5427052 $480.06 $456.06 $524.4727054 $598.97 $569.02 $654.3727060 $371.48 $352.91 $405.8527062 $393.86 $374.17 $430.3027065 $433.49 $411.82 $473.5927066 $713.06 $677.41 $779.0227067 $901.75 $856.66 $985.1627070 $745.82 $708.53 $814.8127071 $809.44 $768.97 $884.3227075 $2,067.64 $1,964.26 $2,258.9027076 $1,424.44 $1,353.22 $1,556.2027077 $2,395.76 $2,275.97 $2,617.3727078 $895.49 $850.72 $978.3327079 $877.12 $833.26 $958.2527080 $424.82 $403.58 $464.1227086 $219.15 $208.19 $239.42

# 27086 $131.66 $125.08 $143.8427087 $557.85 $529.96 $609.4527090 $743.91 $706.71 $812.7227091 $1,414.93 $1,344.18 $1,545.8127093 $186.32 $177.00 $203.55

# 27093 $64.49 $61.27 $70.4627095 $230.49 $218.97 $251.82

# 27095 $72.99 $69.34 $79.7427096 $180.99 $171.94 $197.73

# 27096 $61.52 $58.44 $67.2127097 $580.01 $551.01 $633.6627098 $563.50 $535.33 $615.6327100 $725.04 $688.79 $792.1127105 $761.36 $723.29 $831.7827110 $840.54 $798.51 $918.2927111 $789.04 $749.59 $862.0327120 $1,144.17 $1,086.96 $1,250.00

27122 $990.28 $940.77 $1,081.8927125 $995.92 $946.12 $1,088.0427130 $1,289.93 $1,225.43 $1,409.2427132 $1,513.23 $1,437.57 $1,653.2127134 $1,766.90 $1,678.56 $1,930.3427137 $1,342.91 $1,275.76 $1,467.1227138 $1,397.83 $1,327.94 $1,527.1327140 $805.90 $765.61 $880.4527146 $1,134.01 $1,077.31 $1,238.9127147 $1,300.64 $1,235.61 $1,420.9527151 $1,251.81 $1,189.22 $1,367.6027156 $1,547.86 $1,470.47 $1,691.0427158 $1,154.68 $1,096.95 $1,261.4927161 $1,096.63 $1,041.80 $1,198.0727165 $1,212.43 $1,151.81 $1,324.5827170 $1,057.20 $1,004.34 $1,154.9927175 $582.91 $553.76 $636.8227176 $806.97 $766.62 $881.6127177 $987.55 $938.17 $1,078.9027178 $787.49 $748.12 $860.3427179 $871.23 $827.67 $951.8227181 $937.51 $890.63 $1,024.2227185 $656.09 $623.29 $716.7827187 $893.71 $849.02 $976.3727193 $403.50 $383.33 $440.8327194 $647.79 $615.40 $707.7127200 $146.71 $139.37 $160.28

# 27200 $144.69 $137.46 $158.0827202 $801.71 $761.62 $875.8627215 $656.16 $623.35 $716.8527216 $944.67 $897.44 $1,032.0627217 $909.66 $864.18 $993.8127218 $1,213.60 $1,152.92 $1,325.8627220 $453.38 $430.71 $495.32

# 27220 $450.35 $427.83 $492.0027222 $872.77 $829.13 $953.5027226 $883.08 $838.93 $964.7727227 $1,496.98 $1,422.13 $1,635.4527228 $1,720.42 $1,634.40 $1,879.5627230 $406.77 $386.43 $444.39

# 27230 $396.00 $376.20 $432.6327232 $691.11 $656.55 $755.0327235 $816.13 $775.32 $891.6227236 $1,050.08 $997.58 $1,147.2227238 $391.10 $371.55 $427.2827240 $845.38 $803.11 $923.5827244 $1,041.97 $989.87 $1,138.3527245 $1,280.52 $1,216.49 $1,398.9627246 $334.55 $317.82 $365.49

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 27246 $333.54 $316.86 $364.3927248 $695.21 $660.45 $759.5227250 $419.04 $398.09 $457.8027252 $670.15 $636.64 $732.1427253 $850.65 $808.12 $929.3427254 $1,139.63 $1,082.65 $1,245.0527256 $269.15 $255.69 $294.04

# 27256 $224.39 $213.17 $245.1527257 $297.84 $282.95 $325.3927258 $989.60 $940.12 $1,081.1427259 $1,375.34 $1,306.57 $1,502.5627265 $349.81 $332.32 $382.1727266 $511.48 $485.91 $558.8027275 $160.06 $152.06 $174.8727280 $914.03 $868.33 $998.5827282 $729.64 $693.16 $797.1327284 $1,461.21 $1,388.15 $1,596.3727286 $1,468.10 $1,394.70 $1,603.9127290 $1,406.52 $1,336.19 $1,536.6227295 $1,132.74 $1,076.10 $1,237.5227301 $585.14 $555.88 $639.26

# 27301 $431.01 $409.46 $470.8827303 $565.48 $537.21 $617.7927305 $410.97 $390.42 $448.9827306 $340.60 $323.57 $372.1127307 $414.53 $393.80 $452.8727310 $639.63 $607.65 $698.8027323 $209.62 $199.14 $229.01

# 27323 $150.06 $142.56 $163.9427324 $331.63 $315.05 $362.3127325 $449.09 $426.64 $490.6427326 $424.43 $403.21 $463.6927327 $377.50 $358.63 $412.42

# 27327 $299.77 $284.78 $327.5027328 $363.77 $345.58 $397.4227329 $905.90 $860.61 $989.7027330 $349.69 $332.21 $382.0427331 $416.05 $395.25 $454.5427332 $563.45 $535.28 $615.5727333 $511.90 $486.31 $559.2627334 $601.57 $571.49 $657.2127335 $681.05 $647.00 $744.0527340 $317.11 $301.25 $346.4427345 $420.31 $399.29 $459.1827347 $438.09 $416.19 $478.6227350 $573.98 $545.28 $627.0727355 $533.52 $506.84 $582.8727356 $651.07 $618.52 $711.3027357 $724.29 $688.08 $791.29

27358 $268.17 $254.76 $292.9727360 $757.53 $719.65 $827.6027365 $1,088.31 $1,033.89 $1,188.9727370 $152.04 $144.44 $166.11

# 27370 $46.03 $43.73 $50.2927372 $525.75 $499.46 $574.38

# 27372 $354.79 $337.05 $387.6127380 $526.38 $500.06 $575.0727381 $715.83 $680.04 $782.0527385 $564.56 $536.33 $616.7827386 $743.71 $706.52 $812.5027390 $383.59 $364.41 $419.0727391 $505.01 $479.76 $551.7227392 $624.74 $593.50 $682.5327393 $447.85 $425.46 $489.2827394 $579.56 $550.58 $633.1727395 $783.57 $744.39 $856.0527396 $545.51 $518.23 $595.9627397 $785.04 $745.79 $857.6627400 $592.71 $563.07 $647.5327403 $570.48 $541.96 $623.2527405 $599.12 $569.16 $654.5327407 $691.18 $656.62 $755.1127409 $859.78 $816.79 $939.3127412 $1,470.40 $1,396.88 $1,606.4127415 $1,236.94 $1,175.09 $1,351.3527418 $742.83 $705.69 $811.5427420 $666.49 $633.17 $728.1527422 $663.92 $630.72 $725.3327424 $664.39 $631.17 $725.8527425 $389.06 $369.61 $425.0527427 $637.48 $605.61 $696.4527428 $972.82 $924.18 $1,062.8127429 $1,087.05 $1,032.70 $1,187.6127430 $659.05 $626.10 $720.0227435 $699.87 $664.88 $764.6127437 $585.45 $556.18 $639.6127438 $746.36 $709.04 $815.4027440 $646.42 $614.10 $706.2227441 $685.12 $650.86 $748.4927442 $778.43 $739.51 $850.4427443 $731.04 $694.49 $798.6627445 $1,135.23 $1,078.47 $1,240.2427446 $1,011.56 $960.98 $1,105.1327447 $1,387.82 $1,318.43 $1,516.1927448 $736.51 $699.68 $804.6327450 $915.66 $869.88 $1,000.3627454 $1,157.11 $1,099.25 $1,264.1427455 $846.77 $804.43 $925.09

27457 $872.89 $829.25 $953.6427465 $1,056.66 $1,003.83 $1,154.4027466 $1,061.03 $1,007.98 $1,159.1827468 $1,193.30 $1,133.64 $1,303.6927470 $1,055.68 $1,002.90 $1,153.3427472 $1,146.17 $1,088.86 $1,252.1927475 $585.83 $556.54 $640.0227477 $651.25 $618.69 $711.4927479 $823.63 $782.45 $899.8227485 $597.98 $568.08 $653.2927486 $1,265.46 $1,202.19 $1,382.5227487 $1,601.30 $1,521.24 $1,749.4327488 $1,067.44 $1,014.07 $1,166.1827495 $1,019.55 $968.57 $1,113.8627496 $443.77 $421.58 $484.8227497 $477.32 $453.45 $521.4727498 $527.93 $501.53 $576.7627499 $587.66 $558.28 $642.0227500 $446.10 $423.80 $487.37

# 27500 $411.10 $390.55 $449.1327501 $439.16 $417.20 $479.78

# 27501 $428.05 $406.65 $467.6527502 $706.01 $670.71 $771.3227503 $711.62 $676.04 $777.4527506 $1,180.75 $1,121.71 $1,289.9727507 $889.12 $844.66 $971.3627508 $450.65 $428.12 $492.34

# 27508 $420.70 $399.67 $459.6227509 $574.03 $545.33 $627.1327510 $619.71 $588.72 $677.0327511 $914.02 $868.32 $998.5727513 $1,217.49 $1,156.62 $1,330.1127514 $1,189.24 $1,129.78 $1,299.2527516 $421.02 $399.97 $459.97

# 27516 $394.44 $374.72 $430.9327517 $586.17 $556.86 $640.3927519 $999.80 $949.81 $1,092.2827520 $264.81 $251.57 $289.31

# 27520 $232.16 $220.55 $253.6327524 $674.31 $640.59 $736.6827530 $331.63 $315.05 $362.31

# 27530 $304.37 $289.15 $332.5227532 $535.12 $508.36 $584.61

# 27532 $505.84 $480.55 $552.6327535 $793.88 $754.19 $867.3227536 $1,057.22 $1,004.36 $1,155.0127538 $397.90 $378.01 $434.71

# 27538 $368.96 $350.51 $403.0927540 $842.52 $800.39 $920.45

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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27550 $420.84 $399.80 $459.77# 27550 $387.52 $368.14 $423.36

27552 $546.51 $519.18 $597.0627556 $966.30 $917.99 $1,055.6927557 $1,110.11 $1,054.60 $1,212.7927558 $1,135.97 $1,079.17 $1,241.0527560 $300.74 $285.70 $328.56

# 27560 $254.64 $241.91 $278.2027562 $388.90 $369.46 $424.8827566 $801.57 $761.49 $875.7127570 $128.10 $121.70 $139.9627580 $1,303.07 $1,237.92 $1,423.6127590 $733.27 $696.61 $801.1027591 $819.43 $778.46 $895.2327592 $620.53 $589.50 $677.9327594 $449.08 $426.63 $490.6227596 $655.25 $622.49 $715.8627598 $663.39 $630.22 $724.7527600 $377.78 $358.89 $412.7227601 $387.22 $367.86 $423.0427602 $465.56 $442.28 $508.6227603 $447.03 $424.68 $488.38

# 27603 $336.98 $320.13 $368.1527604 $384.85 $365.61 $420.45

# 27604 $305.77 $290.48 $334.0527605 $350.47 $332.95 $382.89

# 27605 $185.91 $176.61 $203.1027606 $271.72 $258.13 $296.8527607 $538.21 $511.30 $588.0027610 $582.50 $553.38 $636.3927612 $509.77 $484.28 $556.9227613 $195.41 $185.64 $213.49

# 27613 $141.57 $134.49 $154.6627614 $467.15 $443.79 $510.36

# 27614 $366.86 $348.52 $400.8027615 $807.34 $766.97 $882.0227618 $404.38 $384.16 $441.78

# 27618 $331.69 $315.11 $362.3827619 $655.22 $622.46 $715.83

# 27619 $525.32 $499.05 $573.9127620 $414.81 $394.07 $453.1827625 $538.39 $511.47 $588.1927626 $580.71 $551.67 $634.4227630 $447.69 $425.31 $489.11

# 27630 $332.60 $315.97 $363.3727635 $531.21 $504.65 $580.3527637 $672.02 $638.42 $734.1827638 $700.55 $665.52 $765.3527640 $804.82 $764.58 $879.27

27641 $648.17 $615.76 $708.1227645 $968.68 $920.25 $1,058.2927646 $868.58 $825.15 $948.9227647 $745.15 $707.89 $814.0727648 $146.31 $138.99 $159.84

# 27648 $46.03 $43.73 $50.2927650 $634.80 $603.06 $693.5227652 $677.49 $643.62 $740.1627654 $635.24 $603.48 $694.0027656 $463.69 $440.51 $506.59

# 27656 $306.86 $291.52 $335.2527658 $345.72 $328.43 $377.6927659 $458.47 $435.55 $500.8827664 $331.45 $314.88 $362.1127665 $378.98 $360.03 $414.0327675 $468.49 $445.07 $511.8327676 $558.10 $530.20 $609.7327680 $394.37 $374.65 $430.8527681 $464.30 $441.09 $507.2527685 $514.78 $489.04 $562.40

# 27685 $433.34 $411.67 $473.4227686 $511.03 $485.48 $558.3027687 $420.53 $399.50 $459.4327690 $556.77 $528.93 $608.2727691 $657.98 $625.08 $718.8427692 $103.95 $98.75 $113.5627695 $449.85 $427.36 $491.4627696 $539.40 $512.43 $589.2927698 $598.14 $568.23 $653.4627700 $555.63 $527.85 $607.0327702 $903.85 $858.66 $987.4627703 $1,031.79 $980.20 $1,127.2327704 $493.73 $469.04 $539.4027705 $691.30 $656.74 $755.2527707 $347.06 $329.71 $379.1727709 $937.89 $891.00 $1,024.6527712 $965.33 $917.06 $1,054.6227715 $954.71 $906.97 $1,043.0227720 $789.42 $749.95 $862.4427722 $786.73 $747.39 $859.5027724 $1,158.91 $1,100.96 $1,266.1027725 $1,065.13 $1,011.87 $1,163.6527727 $915.84 $870.05 $1,000.5627730 $523.50 $497.33 $571.9327732 $372.61 $353.98 $407.0827734 $553.14 $525.48 $604.3027740 $635.45 $603.68 $694.2327742 $607.54 $577.16 $663.7327745 $677.80 $643.91 $740.50

27750 $285.87 $271.58 $312.32# 27750 $257.94 $245.04 $281.80

27752 $461.33 $438.26 $504.00# 27752 $429.69 $408.21 $469.44

27756 $500.44 $475.42 $546.7327758 $790.44 $750.92 $863.5627759 $901.28 $856.22 $984.6527760 $275.49 $261.72 $300.98

# 27760 $243.19 $231.03 $265.6827762 $416.51 $395.68 $455.03

# 27762 $382.85 $363.71 $418.2727766 $580.75 $551.71 $634.4727780 $244.84 $232.60 $267.49

# 27780 $215.56 $204.78 $235.5027781 $357.07 $339.22 $390.10

# 27781 $330.49 $313.97 $361.0727784 $504.09 $478.89 $550.7227786 $261.36 $248.29 $285.53

# 27786 $227.71 $216.32 $248.7727788 $363.34 $345.17 $396.95

# 27788 $332.38 $315.76 $363.1227792 $539.28 $512.32 $589.1727808 $272.80 $259.16 $298.03

# 27808 $239.15 $227.19 $261.2727810 $408.31 $387.89 $446.07

# 27810 $373.65 $354.97 $408.2227814 $717.88 $681.99 $784.2927816 $259.52 $246.54 $283.52

# 27816 $229.57 $218.09 $250.8027818 $423.84 $402.65 $463.05

# 27818 $385.48 $366.21 $421.1427822 $820.71 $779.67 $896.6227823 $931.44 $884.87 $1,017.6027824 $258.09 $245.19 $281.97

# 27824 $243.96 $231.76 $266.5227825 $475.18 $451.42 $519.13

# 27825 $435.81 $414.02 $476.1227826 $636.53 $604.70 $695.4127827 $1,031.64 $980.06 $1,127.0727828 $1,170.05 $1,111.55 $1,278.2827829 $443.07 $420.92 $484.0627830 $296.20 $281.39 $323.60

# 27830 $278.03 $264.13 $303.7527831 $328.39 $311.97 $358.7727832 $457.60 $434.72 $499.9327840 $299.28 $284.32 $326.9727842 $419.99 $398.99 $458.8427846 $661.53 $628.45 $722.7227848 $769.45 $730.98 $840.63

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

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PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

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PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

27860 $157.63 $149.75 $172.2127870 $940.74 $893.70 $1,027.7627871 $620.36 $589.34 $677.7427880 $815.19 $774.43 $890.5927881 $806.43 $766.11 $881.0327882 $582.72 $553.58 $636.6227884 $523.27 $497.11 $571.6827886 $596.29 $566.48 $651.4527888 $640.98 $608.93 $700.2727889 $622.33 $591.21 $679.8927892 $485.17 $460.91 $530.0527893 $483.02 $458.87 $527.7027894 $736.46 $699.64 $804.5928001 $213.98 $203.28 $233.77

# 28001 $167.88 $159.49 $183.4128002 $400.48 $380.46 $437.53

# 28002 $343.27 $326.11 $375.0328003 $565.88 $537.59 $618.23

# 28003 $513.38 $487.71 $560.8728005 $554.73 $526.99 $606.0428008 $339.75 $322.76 $371.17

# 28008 $279.17 $265.21 $304.9928010 $194.67 $184.94 $212.68

# 28010 $190.30 $180.79 $207.9128011 $278.32 $264.40 $304.06

# 28011 $271.92 $258.32 $297.0728020 $411.82 $391.23 $449.91

# 28020 $332.07 $315.47 $362.7928022 $371.21 $352.65 $405.55

# 28022 $307.27 $291.91 $335.7028024 $358.30 $340.39 $391.45

# 28024 $296.37 $281.55 $323.7828035 $409.44 $388.97 $447.32

# 28035 $333.04 $316.39 $363.8528043 $274.34 $260.62 $299.71

# 28043 $241.02 $228.97 $263.3228045 $379.11 $360.15 $414.17

# 28045 $302.39 $287.27 $330.3628046 $714.61 $678.88 $780.71

# 28046 $618.03 $587.13 $675.2028050 $348.40 $330.98 $380.63

# 28050 $285.13 $270.87 $311.5028052 $331.71 $315.12 $362.39

# 28052 $265.08 $251.83 $289.6028054 $305.97 $290.67 $334.27

# 28054 $239.67 $227.69 $261.8428055 $357.97 $340.07 $391.0828060 $402.29 $382.18 $439.51

# 28060 $331.95 $315.35 $362.65

28062 $483.23 $459.07 $527.93# 28062 $386.31 $366.99 $422.04

28070 $392.64 $373.01 $428.96# 28070 $325.67 $309.39 $355.80

28072 $383.93 $364.73 $419.44# 28072 $319.65 $303.67 $349.22

28080 $368.26 $349.85 $402.33# 28080 $302.98 $287.83 $331.00

28086 $457.03 $434.18 $499.31# 28086 $340.25 $323.24 $371.73

28088 $357.30 $339.44 $390.36# 28088 $278.55 $264.62 $304.31

28090 $359.09 $341.14 $392.31# 28090 $286.07 $271.77 $312.54

28092 $328.94 $312.49 $359.36# 28092 $256.58 $243.75 $280.31

28100 $492.37 $467.75 $537.91# 28100 $375.26 $356.50 $409.98

28102 $496.22 $471.41 $542.1228103 $405.72 $385.43 $443.2428104 $399.47 $379.50 $436.43

# 28104 $328.12 $311.71 $358.4728106 $428.44 $407.02 $468.0728107 $447.26 $424.90 $488.64

# 28107 $354.04 $336.34 $386.7928108 $331.25 $314.69 $361.89

# 28108 $269.00 $255.55 $293.8828110 $349.08 $331.63 $381.37

# 28110 $266.30 $252.99 $290.9428111 $415.21 $394.45 $453.62

# 28111 $315.26 $299.50 $344.4328112 $382.94 $363.79 $418.36

# 28112 $293.09 $278.44 $320.2128113 $445.62 $423.34 $486.84

# 28113 $369.90 $351.41 $404.1228114 $849.20 $806.74 $927.75

# 28114 $724.68 $688.45 $791.7228116 $591.11 $561.55 $645.78

# 28116 $515.72 $489.93 $563.4228118 $457.84 $434.95 $500.19

# 28118 $377.07 $358.22 $411.9528119 $407.26 $386.90 $444.94

# 28119 $333.56 $316.88 $364.4128120 $470.22 $446.71 $513.72

# 28120 $362.86 $344.72 $396.4328122 $535.04 $508.29 $584.53

# 28122 $464.37 $441.15 $507.3228124 $370.13 $351.62 $404.36

# 28124 $308.20 $292.79 $336.71

28126 $293.10 $278.45 $320.22# 28126 $234.55 $222.82 $256.24

28130 $578.26 $549.35 $631.7528140 $518.89 $492.95 $566.89

# 28140 $425.67 $404.39 $465.0528150 $335.00 $318.25 $365.99

# 28150 $267.35 $253.98 $292.0828153 $303.45 $288.28 $331.52

# 28153 $234.46 $222.74 $256.1528160 $314.85 $299.11 $343.98

# 28160 $254.94 $242.19 $278.5228171 $562.53 $534.40 $614.5628173 $612.37 $581.75 $669.01

# 28173 $516.79 $490.95 $564.5928175 $439.29 $417.33 $479.93

# 28175 $359.19 $341.23 $392.4128190 $194.26 $184.55 $212.23

# 28190 $123.59 $117.41 $135.0228192 $375.46 $356.69 $410.19

# 28192 $299.74 $284.75 $327.4628193 $425.39 $404.12 $464.74

# 28193 $351.69 $334.11 $384.2328200 $365.87 $347.58 $399.72

# 28200 $296.20 $281.39 $323.6028202 $517.29 $491.43 $565.14

# 28202 $415.66 $394.88 $454.1128208 $348.20 $330.79 $380.41

# 28208 $280.56 $266.53 $306.5128210 $466.45 $443.13 $509.60

# 28210 $380.63 $361.60 $415.8428220 $347.45 $330.08 $379.59

# 28220 $287.88 $273.49 $314.5128222 $407.10 $386.75 $444.76

# 28222 $348.88 $331.44 $381.1628225 $300.72 $285.68 $328.53

# 28225 $238.12 $226.21 $260.1428226 $355.52 $337.74 $388.40

# 28226 $298.31 $283.39 $325.9028230 $335.54 $318.76 $366.57

# 28230 $281.70 $267.62 $307.7628232 $295.96 $281.16 $323.33

# 28232 $237.74 $225.85 $259.7328234 $302.69 $287.56 $330.69

# 28234 $242.12 $230.01 $264.5128238 $556.65 $528.82 $608.14

# 28238 $464.78 $441.54 $507.7728240 $340.71 $323.67 $372.22

# 28240 $282.83 $268.69 $308.9928250 $435.80 $414.01 $476.11

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

# 28250 $367.15 $348.79 $401.1128260 $546.08 $518.78 $596.60

# 28260 $479.78 $455.79 $524.1628261 $800.95 $760.90 $875.04

# 28261 $731.29 $694.73 $798.9428262 $1,140.04 $1,083.04 $1,245.50

# 28262 $1,024.95 $973.70 $1,119.7628264 $693.61 $658.93 $757.77

# 28264 $645.48 $613.21 $705.1928270 $367.55 $349.17 $401.55

# 28270 $308.99 $293.54 $337.5728272 $301.23 $286.17 $329.10

# 28272 $240.65 $228.62 $262.9128280 $422.60 $401.47 $461.69

# 28280 $346.54 $329.21 $378.5928285 $357.79 $339.90 $390.89

# 28285 $293.18 $278.52 $320.3028286 $352.29 $334.68 $384.88

# 28286 $284.31 $270.09 $310.6028288 $442.66 $420.53 $483.61

# 28288 $383.43 $364.26 $418.9028289 $591.97 $562.37 $646.73

# 28289 $501.44 $476.37 $547.8328290 $449.30 $426.84 $490.87

# 28290 $375.26 $356.50 $409.9828292 $603.76 $573.57 $659.61

# 28292 $519.96 $493.96 $568.0528293 $810.32 $769.80 $885.27

# 28293 $629.26 $597.80 $687.4728294 $595.62 $565.84 $650.72

# 28294 $488.60 $464.17 $533.8028296 $644.28 $612.07 $703.88

# 28296 $534.91 $508.16 $584.3828297 $675.54 $641.76 $738.02

# 28297 $564.49 $536.27 $616.7128298 $568.35 $539.93 $620.92

# 28298 $473.12 $449.46 $516.8828299 $744.71 $707.47 $813.59

# 28299 $636.01 $604.21 $694.8428300 $607.97 $577.57 $664.2128302 $597.62 $567.74 $652.9028304 $640.52 $608.49 $699.76

# 28304 $547.30 $519.94 $597.9328305 $622.39 $591.27 $679.9628306 $472.60 $448.97 $516.32

# 28306 $367.94 $349.54 $401.9728307 $606.33 $576.01 $662.41

# 28307 $419.22 $398.26 $458.0028308 $418.02 $397.12 $456.69

# 28308 $331.54 $314.96 $362.2028309 $811.23 $770.67 $886.2728310 $418.83 $397.89 $457.57

# 28310 $328.97 $312.52 $359.4028312 $377.47 $358.60 $412.39

# 28312 $297.04 $282.19 $324.5228313 $391.97 $372.37 $428.23

# 28313 $349.90 $332.41 $382.2728315 $368.90 $350.46 $403.03

# 28315 $300.25 $285.24 $328.0328320 $581.41 $552.34 $635.1928322 $644.86 $612.62 $704.51

# 28322 $535.15 $508.39 $584.6528340 $498.76 $473.82 $544.89

# 28340 $409.92 $389.42 $447.8328341 $575.33 $546.56 $628.54

# 28341 $486.48 $462.16 $531.4828344 $366.31 $347.99 $400.19

# 28344 $282.51 $268.38 $308.6428345 $452.68 $430.05 $494.56

# 28345 $382.01 $362.91 $417.3528360 $894.26 $849.55 $976.9828400 $207.61 $197.23 $226.81

# 28400 $189.10 $179.65 $206.6028405 $342.19 $325.08 $373.84

# 28405 $330.41 $313.89 $360.9728406 $475.86 $452.07 $519.8828415 $1,114.80 $1,059.06 $1,217.9228420 $1,087.69 $1,033.31 $1,188.3128430 $195.17 $185.41 $213.22

# 28430 $169.59 $161.11 $185.2828435 $265.73 $252.44 $290.31

# 28435 $256.30 $243.49 $280.0128436 $381.46 $362.39 $416.7528445 $1,028.86 $977.42 $1,124.0328450 $178.97 $170.02 $195.52

# 28450 $158.44 $150.52 $173.1028455 $239.37 $227.40 $261.51

# 28455 $233.99 $222.29 $255.6328456 $243.57 $231.39 $266.1028465 $481.86 $457.77 $526.4428470 $180.48 $171.46 $197.18

# 28470 $159.62 $151.64 $174.3928475 $226.58 $215.25 $247.54

# 28475 $218.50 $207.58 $238.7228476 $298.41 $283.49 $326.0128485 $400.37 $380.35 $437.4028490 $111.60 $106.02 $121.92

# 28490 $98.47 $93.55 $107.58

28495 $137.72 $130.83 $150.45# 28495 $129.98 $123.48 $142.00

28496 $362.37 $344.25 $395.89# 28496 $198.48 $188.56 $216.84

28505 $417.72 $396.83 $456.35# 28505 $276.38 $262.56 $301.94

28510 $95.78 $90.99 $104.64# 28510 $95.11 $90.35 $103.90

28515 $123.80 $117.61 $135.25# 28515 $120.43 $114.41 $131.57

28525 $378.86 $359.92 $413.91# 28525 $242.56 $230.43 $264.99

28530 $91.57 $86.99 $100.04# 28530 $89.22 $84.76 $97.47

28531 $329.53 $313.05 $360.01# 28531 $166.99 $158.64 $182.44

28540 $164.43 $156.21 $179.64# 28540 $160.73 $152.69 $175.59

28545 $185.15 $175.89 $202.27# 28545 $180.10 $171.10 $196.77

28546 $368.08 $349.68 $402.13# 28546 $269.14 $255.68 $294.03

28555 $585.84 $556.55 $640.03# 28555 $438.44 $416.52 $479.00

28570 $148.78 $141.34 $162.54# 28570 $141.37 $134.30 $154.45

28575 $264.79 $251.55 $289.28# 28575 $258.74 $245.80 $282.67

28576 $315.06 $299.31 $344.2128585 $588.78 $559.34 $643.24

# 28585 $512.39 $486.77 $559.7928600 $171.53 $162.95 $187.39

# 28600 $162.78 $154.64 $177.8428605 $218.47 $207.55 $238.68

# 28605 $213.42 $202.75 $233.1628606 $351.55 $333.97 $384.0728615 $610.97 $580.42 $667.4828630 $121.61 $115.53 $132.86

# 28630 $98.73 $93.79 $107.8628635 $144.95 $137.70 $158.36

# 28635 $124.42 $118.20 $135.9328636 $242.98 $230.83 $265.45

# 28636 $192.16 $182.55 $209.9328645 $347.61 $330.23 $379.76

# 28645 $274.24 $260.53 $299.6128660 $89.52 $85.04 $97.80

# 28660 $73.37 $69.70 $80.1628665 $126.44 $120.12 $138.14

# 28665 $122.06 $115.96 $133.35

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

28666 $186.36 $177.04 $203.6028675 $352.77 $335.13 $385.40

# 28675 $224.89 $213.65 $245.7028705 $1,194.18 $1,134.47 $1,304.6428715 $881.50 $837.43 $963.0428725 $737.39 $700.52 $805.6028730 $753.14 $715.48 $822.8028735 $723.18 $687.02 $790.0728737 $641.94 $609.84 $701.3228740 $717.17 $681.31 $783.51

# 28740 $565.06 $536.81 $617.3328750 $715.11 $679.35 $781.25

# 28750 $541.46 $514.39 $591.5528755 $400.39 $380.37 $437.43

# 28755 $308.19 $292.78 $336.7028760 $625.43 $594.16 $683.28

# 28760 $524.47 $498.25 $572.9928800 $522.32 $496.20 $570.6328805 $660.38 $627.36 $721.4628810 $398.50 $378.58 $435.3728820 $442.86 $420.72 $483.83

# 28820 $312.95 $297.30 $341.9028825 $380.17 $361.16 $415.33

# 28825 $257.67 $244.79 $281.5128890 $312.54 $296.91 $341.45

# 28890 $200.48 $190.46 $219.0329000 $204.65 $194.42 $223.58

# 29000 $149.46 $141.99 $163.2929010 $196.17 $186.36 $214.31

# 29010 $140.98 $133.93 $154.0229015 $194.89 $185.15 $212.92

# 29015 $144.41 $137.19 $157.7729020 $193.74 $184.05 $211.66

# 29020 $129.80 $123.31 $141.8129025 $206.24 $195.93 $225.32

# 29025 $156.77 $148.93 $171.2729035 $191.76 $182.17 $209.50

# 29035 $121.76 $115.67 $133.0229040 $180.35 $171.33 $197.03

# 29040 $138.62 $131.69 $151.4429044 $217.32 $206.45 $237.42

# 29044 $145.98 $138.68 $159.4829046 $213.02 $202.37 $232.73

# 29046 $164.22 $156.01 $179.4129049 $77.06 $73.21 $84.19

# 29049 $53.16 $50.50 $58.0829055 $170.25 $161.74 $186.00

# 29055 $118.76 $112.82 $129.7429058 $100.19 $95.18 $109.46

# 29058 $74.28 $70.57 $81.1629065 $78.98 $75.03 $86.28

# 29065 $59.47 $56.50 $64.9829075 $72.55 $68.92 $79.26

# 29075 $53.37 $50.70 $58.3129085 $77.30 $73.44 $84.46

# 29085 $56.10 $53.30 $61.3029086 $56.54 $53.71 $61.77

# 29086 $40.38 $38.36 $44.1129105 $73.95 $70.25 $80.79

# 29105 $51.06 $48.51 $55.7929125 $56.41 $53.59 $61.63

# 29125 $35.88 $34.09 $39.2029126 $67.52 $64.14 $73.76

# 29126 $44.30 $42.09 $48.4029130 $34.54 $32.81 $37.73

# 29130 $25.11 $23.85 $27.4329131 $43.46 $41.29 $47.48

# 29131 $27.98 $26.58 $30.5729200 $46.54 $44.21 $50.84

# 29200 $34.76 $33.02 $37.9729220 $46.54 $44.21 $50.84

# 29220 $36.10 $34.30 $39.4529240 $53.51 $50.83 $58.45

# 29240 $38.71 $36.77 $42.2929260 $44.47 $42.25 $48.59

# 29260 $31.34 $29.77 $34.2429280 $44.35 $42.13 $48.45

# 29280 $29.54 $28.06 $32.2729305 $193.76 $184.07 $211.68

# 29305 $138.91 $131.96 $151.7529325 $212.69 $202.06 $232.37

# 29325 $156.49 $148.67 $170.9729345 $114.31 $108.59 $124.88

# 29345 $90.42 $85.90 $98.7929355 $117.84 $111.95 $128.74

# 29355 $97.31 $92.44 $106.3129358 $126.55 $120.22 $138.25

# 29358 $92.56 $87.93 $101.1229365 $102.03 $96.93 $111.47

# 29365 $78.14 $74.23 $85.3629405 $74.91 $71.16 $81.83

# 29405 $57.41 $54.54 $62.7229425 $80.88 $76.84 $88.37

# 29425 $63.72 $60.53 $69.6129435 $99.00 $94.05 $108.16

# 29435 $77.13 $73.27 $84.2629440 $44.54 $42.31 $48.66

# 29440 $31.08 $29.53 $33.96

29445 $128.87 $122.43 $140.79# 29445 $101.95 $96.85 $111.38

29450 $130.02 $123.52 $142.05# 29450 $114.87 $109.13 $125.50

29505 $64.87 $61.63 $70.87# 29505 $41.31 $39.24 $45.13

29515 $57.96 $55.06 $63.32# 29515 $43.49 $41.32 $47.52

29520 $46.83 $44.49 $51.16# 29520 $34.71 $32.97 $37.92

29530 $46.23 $43.92 $50.51# 29530 $32.44 $30.82 $35.44

29540 $34.58 $32.85 $37.78# 29540 $29.87 $28.38 $32.64

29550 $33.40 $31.73 $36.49# 29550 $27.68 $26.30 $30.25

29580 $43.45 $41.28 $47.47# 29580 $32.68 $31.05 $35.71

29590 $46.94 $44.59 $51.28# 29590 $38.53 $36.60 $42.09

29700 $52.62 $49.99 $57.49# 29700 $31.42 $29.85 $34.33

29705 $57.36 $54.49 $62.66# 29705 $42.89 $40.75 $46.86

29710 $103.34 $98.17 $112.90# 29710 $75.75 $71.96 $82.75

29715 $74.25 $70.54 $81.12# 29715 $48.68 $46.25 $53.19

29720 $66.16 $62.85 $72.28# 29720 $39.91 $37.91 $43.60

29730 $56.32 $53.50 $61.53# 29730 $41.17 $39.11 $44.98

29740 $82.31 $78.19 $89.92# 29740 $60.77 $57.73 $66.39

29750 $84.49 $80.27 $92.31# 29750 $68.34 $64.92 $74.66

29800 $480.03 $456.03 $524.4329804 $583.04 $553.89 $636.9729805 $419.46 $398.49 $458.2629806 $954.19 $906.48 $1,042.4529807 $929.84 $883.35 $1,015.8529819 $524.97 $498.72 $573.5329820 $484.14 $459.93 $528.9229821 $529.39 $502.92 $578.3629822 $514.51 $488.78 $562.1029823 $561.40 $533.33 $613.3329824 $593.55 $563.87 $648.4529825 $524.30 $498.09 $572.8029826 $602.82 $572.68 $658.58

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

29827 $985.96 $936.66 $1,077.1629830 $403.82 $383.63 $441.1729834 $440.11 $418.10 $480.8229835 $450.62 $428.09 $492.3029836 $518.31 $492.39 $566.2529837 $473.62 $449.94 $517.4329838 $530.37 $503.85 $579.4329840 $392.29 $372.68 $428.5829843 $420.63 $399.60 $459.5429844 $442.15 $420.04 $483.0529845 $501.47 $476.40 $547.8629846 $463.48 $440.31 $506.3629847 $479.18 $455.22 $523.5029848 $427.39 $406.02 $466.9229850 $492.24 $467.63 $537.7729851 $841.06 $799.01 $918.8629855 $706.22 $670.91 $771.5529856 $904.26 $859.05 $987.9129860 $575.19 $546.43 $628.3929861 $633.50 $601.83 $692.1029862 $708.40 $672.98 $773.9329863 $699.72 $664.73 $764.4429866 $940.62 $893.59 $1,027.6329867 $1,141.41 $1,084.34 $1,246.9929868 $1,535.41 $1,458.64 $1,677.4429870 $361.52 $343.44 $394.9629871 $453.61 $430.93 $495.5729873 $455.39 $432.62 $497.5129874 $476.05 $452.25 $520.0929875 $442.25 $420.14 $483.1629876 $572.66 $544.03 $625.6329877 $541.24 $514.18 $591.3129879 $580.18 $551.17 $633.8529880 $606.13 $575.82 $662.1929881 $564.33 $536.11 $616.5329882 $609.74 $579.25 $666.1429883 $753.13 $715.47 $822.7929884 $539.14 $512.18 $589.0129885 $655.34 $622.57 $715.9629886 $551.71 $524.12 $602.7429887 $652.14 $619.53 $712.4629888 $890.88 $846.34 $973.2929889 $1,081.93 $1,027.83 $1,182.0029891 $615.25 $584.49 $672.1629892 $641.43 $609.36 $700.7629893 $461.86 $438.77 $504.59

# 29893 $368.98 $350.53 $403.1129894 $463.85 $440.66 $506.7629895 $453.59 $430.91 $495.55

29897 $475.83 $452.04 $519.8529898 $529.68 $503.20 $578.6829899 $943.42 $896.25 $1,030.6929900 $415.36 $394.59 $453.7829901 $460.10 $437.10 $502.6729902 $472.68 $449.05 $516.4130000 $187.21 $177.85 $204.53

# 30000 $98.70 $93.77 $107.8430020 $168.36 $159.94 $183.93

# 30020 $101.06 $96.01 $110.4130100 $104.55 $99.32 $114.22

# 30100 $61.13 $58.07 $66.7830110 $173.16 $164.50 $189.18

# 30110 $111.57 $105.99 $121.8930115 $354.81 $337.07 $387.6330117 $591.99 $562.39 $646.75

# 30117 $272.96 $259.31 $298.2130118 $658.43 $625.51 $719.3430120 $420.60 $399.57 $459.51

# 30120 $391.66 $372.08 $427.8930124 $237.03 $225.18 $258.9630125 $535.81 $509.02 $585.3730130 $312.45 $296.83 $341.3530140 $341.97 $324.87 $373.6030150 $703.43 $668.26 $768.5030160 $693.03 $658.38 $757.1430200 $85.40 $81.13 $93.30

# 30200 $52.42 $49.80 $57.2730210 $113.21 $107.55 $123.68

# 30210 $83.60 $79.42 $91.3330220 $209.51 $199.03 $228.88

# 30220 $106.86 $101.52 $116.7530300 $190.45 $180.93 $208.07

# 30300 $101.94 $96.84 $111.3730310 $174.09 $165.39 $190.2030320 $396.55 $376.72 $433.2330400 $902.62 $857.49 $986.1130410 $1,100.24 $1,045.23 $1,202.0130420 $1,192.74 $1,133.10 $1,303.0730430 $809.56 $769.08 $884.4430435 $1,078.63 $1,024.70 $1,178.4130450 $1,416.48 $1,345.66 $1,547.5130460 $695.35 $660.58 $759.6730462 $1,404.00 $1,333.80 $1,533.8730465 $840.79 $798.75 $918.5630520 $479.31 $455.34 $523.6430540 $581.84 $552.75 $635.6630545 $834.55 $792.82 $911.7430560 $208.79 $198.35 $228.10

# 30560 $116.58 $110.75 $127.3630580 $525.28 $499.02 $573.87

# 30580 $446.20 $423.89 $487.4730600 $483.34 $459.17 $528.05

# 30600 $391.46 $371.89 $427.6730620 $516.23 $490.42 $563.9830630 $525.97 $499.67 $574.6230801 $178.88 $169.94 $195.43

# 30801 $105.85 $100.56 $115.6430802 $230.21 $218.70 $251.51

# 30802 $154.15 $146.44 $168.4130901 $89.40 $84.93 $97.67

# 30901 $55.41 $52.64 $60.5430903 $151.24 $143.68 $165.23

# 30903 $72.83 $69.19 $79.5730905 $192.89 $183.25 $210.74

# 30905 $95.97 $91.17 $104.8530906 $221.63 $210.55 $242.13

# 30906 $126.05 $119.75 $137.7130915 $488.63 $464.20 $533.8330920 $698.43 $663.51 $763.0430930 $101.43 $96.36 $110.8131000 $139.71 $132.72 $152.63

# 31000 $88.56 $84.13 $96.7531002 $173.92 $165.22 $190.0031020 $394.97 $375.22 $431.50

# 31020 $285.94 $271.64 $312.3931030 $595.30 $565.54 $650.37

# 31030 $441.84 $419.75 $482.7131032 $482.76 $458.62 $527.4131040 $667.61 $634.23 $729.3631050 $409.84 $389.35 $447.7531051 $538.00 $511.10 $587.7731070 $357.97 $340.07 $391.0831075 $663.27 $630.11 $724.6331080 $898.25 $853.34 $981.3431081 $1,037.00 $985.15 $1,132.9231084 $984.11 $934.90 $1,075.1431085 $1,046.15 $993.84 $1,142.9231086 $953.29 $905.63 $1,041.4731087 $945.95 $898.65 $1,033.4531090 $823.36 $782.19 $899.5231200 $476.10 $452.30 $520.1531201 $618.41 $587.49 $675.6131205 $759.95 $721.95 $830.2431225 $1,543.16 $1,466.00 $1,685.9031230 $1,735.19 $1,648.43 $1,895.6931231 $153.93 $146.23 $168.16

# 31231 $68.79 $65.35 $75.15

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

31233 $222.63 $211.50 $243.23# 31233 $127.05 $120.70 $138.81

31235 $258.68 $245.75 $282.61# 31235 $151.66 $144.08 $165.69

31237 $280.18 $266.17 $306.10# 31237 $168.79 $160.35 $184.40

31238 $289.66 $275.18 $316.46# 31238 $183.98 $174.78 $201.00

31239 $590.65 $561.12 $645.2931240 $150.57 $143.04 $164.5031254 $259.53 $246.55 $283.5331255 $385.38 $366.11 $421.0331256 $187.80 $178.41 $205.1731267 $303.65 $288.47 $331.7431276 $486.10 $461.80 $531.0731287 $221.12 $210.06 $241.5731288 $256.58 $243.75 $280.3131290 $1,050.52 $997.99 $1,147.6931291 $1,107.88 $1,052.49 $1,210.3631292 $908.30 $862.89 $992.3231293 $988.97 $939.52 $1,080.4531294 $1,139.42 $1,082.45 $1,244.8231300 $1,066.85 $1,013.51 $1,165.5431320 $544.26 $517.05 $594.6131360 $1,630.24 $1,548.73 $1,781.0431365 $2,067.17 $1,963.81 $2,258.3831367 $1,815.01 $1,724.26 $1,982.9031368 $2,059.54 $1,956.56 $2,250.0431370 $1,719.77 $1,633.78 $1,878.8531375 $1,609.75 $1,529.26 $1,758.6531380 $1,598.06 $1,518.16 $1,745.8831382 $1,737.75 $1,650.86 $1,898.4931390 $2,326.56 $2,210.23 $2,541.7631395 $2,497.31 $2,372.44 $2,728.3131400 $863.72 $820.53 $943.6131420 $721.07 $685.02 $787.7731500 $102.75 $97.61 $112.2531502 $32.40 $30.78 $35.4031505 $70.30 $66.79 $76.81

# 31505 $42.70 $40.57 $46.6631510 $179.26 $170.30 $195.85

# 31510 $110.27 $104.76 $120.4731511 $181.83 $172.74 $198.65

# 31511 $114.52 $108.79 $125.1131512 $180.14 $171.13 $196.80

# 31512 $118.90 $112.96 $129.9031513 $122.39 $116.27 $133.7131515 $181.16 $172.10 $197.92

# 31515 $100.05 $95.05 $109.31

31520 $142.63 $135.50 $155.8331525 $215.95 $205.15 $235.92

# 31525 $148.31 $140.89 $162.0231526 $147.38 $140.01 $161.0131527 $178.31 $169.39 $194.8031528 $132.15 $125.54 $144.3731529 $151.17 $143.61 $165.1531530 $185.12 $175.86 $202.2431531 $201.03 $190.98 $219.6331535 $177.55 $168.67 $193.9731536 $199.22 $189.26 $217.6531540 $229.01 $217.56 $250.1931541 $251.05 $238.50 $274.2831545 $333.90 $317.21 $364.7931546 $514.78 $489.04 $562.4031560 $295.61 $280.83 $322.9531561 $323.25 $307.09 $353.1531570 $318.18 $302.27 $347.61

# 31570 $214.53 $203.80 $234.3731571 $236.24 $224.43 $258.0931575 $101.77 $96.68 $111.18

# 31575 $68.79 $65.35 $75.1531576 $191.89 $182.30 $209.65

# 31576 $112.47 $106.85 $122.8831577 $213.30 $202.64 $233.04

# 31577 $139.26 $132.30 $152.1531578 $243.30 $231.14 $265.81

# 31578 $152.77 $145.13 $166.9031579 $200.72 $190.68 $219.28

# 31579 $129.04 $122.59 $140.9831580 $1,041.62 $989.54 $1,137.9731582 $1,662.07 $1,578.97 $1,815.8231584 $1,329.38 $1,262.91 $1,452.3531587 $849.29 $806.83 $927.8531588 $973.55 $924.87 $1,063.6031590 $781.68 $742.60 $853.9931595 $662.51 $629.38 $723.7931600 $370.40 $351.88 $404.6631601 $238.92 $226.97 $261.0231603 $208.49 $198.07 $227.7831605 $172.01 $163.41 $187.9231610 $612.06 $581.46 $668.6831611 $449.83 $427.34 $491.4431612 $70.43 $66.91 $76.95

# 31612 $44.85 $42.61 $49.0031613 $371.56 $352.98 $405.9331614 $602.92 $572.77 $658.6931615 $160.72 $152.68 $175.58

# 31615 $114.95 $109.20 $125.58

31620 $244.25 $232.04 $266.85# 31620 $68.25 $64.84 $74.57

31622 $287.52 $273.14 $314.11# 31622 $135.07 $128.32 $147.57

31623 $315.18 $299.42 $344.33# 31623 $136.82 $129.98 $149.48

31624 $293.30 $278.64 $320.44# 31624 $136.82 $129.98 $149.48

31625 $313.28 $297.62 $342.26# 31625 $159.83 $151.84 $174.62

31628 $371.86 $353.27 $406.26# 31628 $178.02 $169.12 $194.49

31629 $605.84 $575.55 $661.88# 31629 $190.23 $180.72 $207.83

31630 $194.84 $185.10 $212.8731631 $216.10 $205.30 $236.1031632 $69.18 $65.72 $75.58

# 31632 $51.34 $48.77 $56.0931633 $82.07 $77.97 $89.67

# 31633 $63.22 $60.06 $69.0731635 $330.95 $314.40 $361.56

# 31635 $178.83 $169.89 $195.3731636 $213.20 $202.54 $232.9231637 $75.99 $72.19 $83.0231638 $236.64 $224.81 $258.5331640 $248.51 $236.08 $271.4931641 $242.83 $230.69 $265.2931643 $165.72 $157.43 $181.0431645 $282.91 $268.76 $309.07

# 31645 $149.65 $142.17 $163.5031646 $257.71 $244.82 $281.54

# 31646 $130.16 $123.65 $142.2031656 $307.41 $292.04 $335.85

# 31656 $105.49 $100.22 $115.2531715 $51.34 $48.77 $56.0931717 $334.50 $317.78 $365.45

# 31717 $103.64 $98.46 $113.2331720 $48.77 $46.33 $53.2831725 $89.88 $85.39 $98.2031730 $372.57 $353.94 $407.03

# 31730 $135.65 $128.87 $148.2031750 $1,132.20 $1,075.59 $1,236.9331755 $1,435.58 $1,363.80 $1,568.3731760 $1,246.96 $1,184.61 $1,362.3031766 $1,668.22 $1,584.81 $1,822.5331770 $1,227.60 $1,166.22 $1,341.1531775 $1,308.52 $1,243.09 $1,429.5531780 $1,073.87 $1,020.18 $1,173.2131781 $1,303.37 $1,238.20 $1,423.93

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

31785 $980.66 $931.63 $1,071.3731786 $1,386.66 $1,317.33 $1,514.9331800 $605.83 $575.54 $661.8731805 $751.03 $713.48 $820.5031820 $357.60 $339.72 $390.68

# 31820 $286.26 $271.95 $312.7431825 $506.72 $481.38 $553.59

# 31825 $425.62 $404.34 $464.9931830 $362.13 $344.02 $395.62

# 31830 $298.19 $283.28 $325.7732000 $151.59 $144.01 $165.61

# 32000 $70.83 $67.29 $77.3832002 $182.65 $173.52 $199.55

# 32002 $113.32 $107.65 $123.8032005 $287.61 $273.23 $314.21

# 32005 $104.88 $99.64 $114.5932019 $787.45 $748.08 $860.29

# 32019 $209.63 $199.15 $229.0232020 $168.58 $160.15 $184.1732035 $622.54 $591.41 $680.1232036 $679.86 $645.87 $742.7532095 $562.69 $534.56 $614.7432100 $879.47 $835.50 $960.8332110 $1,319.67 $1,253.69 $1,441.7432120 $776.83 $737.99 $848.6932124 $827.26 $785.90 $903.7932140 $886.05 $841.75 $968.0132141 $1,268.23 $1,204.82 $1,385.5432150 $891.34 $846.77 $973.7932151 $917.04 $871.19 $1,001.8732160 $669.53 $636.05 $731.4632200 $992.32 $942.70 $1,084.1132201 $824.18 $782.97 $900.42

# 32201 $186.46 $177.14 $203.7132215 $724.94 $688.69 $791.9932220 $1,447.53 $1,375.15 $1,581.4232225 $892.42 $847.80 $974.9732310 $828.24 $786.83 $904.8532320 $1,443.23 $1,371.07 $1,576.7332400 $133.55 $126.87 $145.90

# 32400 $81.05 $77.00 $88.5532402 $508.14 $482.73 $555.1432405 $91.15 $86.59 $99.58

# 32405 $90.14 $85.63 $98.4732420 $100.49 $95.47 $109.7932440 $1,467.92 $1,394.52 $1,603.7032442 $2,578.49 $2,449.57 $2,817.0132445 $2,840.34 $2,698.32 $3,103.0732480 $1,384.30 $1,315.09 $1,512.35

32482 $1,472.39 $1,398.77 $1,608.5932484 $1,332.05 $1,265.45 $1,455.2732486 $2,038.12 $1,936.21 $2,226.6432488 $2,066.77 $1,963.43 $2,257.9432491 $1,363.27 $1,295.11 $1,489.3832500 $1,342.35 $1,275.23 $1,466.5132501 $231.71 $220.12 $253.1432503 $1,707.09 $1,621.74 $1,865.0032504 $1,946.99 $1,849.64 $2,127.0932540 $1,445.04 $1,372.79 $1,578.7132601 $289.44 $274.97 $316.2232602 $314.22 $298.51 $343.2932603 $405.69 $385.41 $443.2232604 $453.44 $430.77 $495.3932605 $363.64 $345.46 $397.2832606 $436.19 $414.38 $476.5432650 $634.96 $603.21 $693.6932651 $947.49 $900.12 $1,035.1432652 $1,429.74 $1,358.25 $1,561.9932653 $918.56 $872.63 $1,003.5232654 $1,008.02 $957.62 $1,101.2632655 $853.71 $811.02 $932.6732656 $763.50 $725.33 $834.1332657 $749.79 $712.30 $819.1532658 $686.74 $652.40 $750.2632659 $696.32 $661.50 $760.7332660 $974.85 $926.11 $1,065.0332661 $765.56 $727.28 $836.3732662 $859.89 $816.90 $939.4432663 $1,279.54 $1,215.56 $1,397.8932664 $808.75 $768.31 $883.5632665 $1,081.05 $1,027.00 $1,181.0532800 $844.37 $802.15 $922.4732810 $819.96 $778.96 $895.8032815 $2,242.92 $2,130.77 $2,450.3932820 $1,251.88 $1,189.29 $1,367.6832851 $2,455.45 $2,332.68 $2,682.5832852 $2,759.24 $2,621.28 $3,014.4732853 $2,941.30 $2,794.24 $3,213.3832854 $3,177.08 $3,018.23 $3,470.9632900 $1,237.46 $1,175.59 $1,351.9332905 $1,231.70 $1,170.12 $1,345.6432906 $1,526.96 $1,450.61 $1,668.2032940 $1,131.47 $1,074.90 $1,236.1432960 $124.40 $118.18 $135.91

# 32960 $87.39 $83.02 $95.4732997 $331.27 $314.71 $361.9232998 $2,515.60 $2,389.82 $2,748.29

# 32998 $265.23 $251.97 $289.77

33010 $109.45 $103.98 $119.5833011 $111.13 $105.57 $121.4133015 $476.91 $453.06 $521.0233020 $792.53 $752.90 $865.8433025 $736.08 $699.28 $804.1733030 $1,171.82 $1,113.23 $1,280.2133031 $1,303.75 $1,238.56 $1,424.3433050 $907.67 $862.29 $991.6333120 $1,437.55 $1,365.67 $1,570.5233130 $1,254.95 $1,192.20 $1,371.0333140 $1,422.86 $1,351.72 $1,554.4833141 $156.20 $148.39 $170.6533202 $714.68 $678.95 $780.7933203 $732.51 $695.88 $800.2633206 $422.48 $401.36 $461.5633207 $494.74 $470.00 $540.5033208 $461.91 $438.81 $504.6333210 $164.66 $156.43 $179.8933211 $170.04 $161.54 $185.7733212 $318.75 $302.81 $348.2333213 $362.02 $343.92 $395.5133214 $453.90 $431.21 $495.8933215 $289.13 $274.67 $315.8733216 $355.25 $337.49 $388.1133217 $355.12 $337.36 $387.9633218 $365.27 $347.01 $399.0633220 $367.92 $349.52 $401.9533222 $329.97 $313.47 $360.4933223 $394.50 $374.78 $431.0033224 $470.15 $446.64 $513.6433225 $419.00 $398.05 $457.7633226 $453.63 $430.95 $495.5933233 $231.75 $220.16 $253.1833234 $457.19 $434.33 $499.4833235 $596.99 $567.14 $652.2133236 $730.90 $694.36 $798.5133237 $782.97 $743.82 $855.3933238 $865.38 $822.11 $945.4333240 $434.09 $412.39 $474.2533241 $217.67 $206.79 $237.8133243 $1,250.12 $1,187.61 $1,365.7533244 $810.41 $769.89 $885.3733249 $836.85 $795.01 $914.2633250 $1,348.68 $1,281.25 $1,473.4433251 $1,489.29 $1,414.83 $1,627.0533254 $1,250.04 $1,187.54 $1,365.6733255 $1,506.10 $1,430.80 $1,645.4233256 $1,800.08 $1,710.08 $1,966.5933261 $1,488.99 $1,414.54 $1,626.72

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

33265 $1,250.04 $1,187.54 $1,365.6733266 $1,712.60 $1,626.97 $1,871.0233282 $305.95 $290.65 $334.2533284 $225.91 $214.61 $246.8033300 $1,983.09 $1,883.94 $2,166.5333305 $3,203.75 $3,043.56 $3,500.0933310 $1,091.73 $1,037.14 $1,192.7133315 $1,359.77 $1,291.78 $1,485.5533320 $979.13 $930.17 $1,069.7033321 $1,136.58 $1,079.75 $1,241.7133322 $1,267.75 $1,204.36 $1,385.0133330 $1,292.95 $1,228.30 $1,412.5533332 $1,280.75 $1,216.71 $1,399.2233335 $1,740.01 $1,653.01 $1,900.9633400 $2,070.20 $1,966.69 $2,261.6933401 $1,373.93 $1,305.23 $1,501.0133403 $1,433.24 $1,361.58 $1,565.8233404 $1,679.50 $1,595.53 $1,834.8633405 $2,173.48 $2,064.81 $2,374.5333406 $2,613.21 $2,482.55 $2,854.9333410 $2,294.36 $2,179.64 $2,506.5933411 $2,948.24 $2,800.83 $3,220.9533412 $2,358.67 $2,240.74 $2,576.8533413 $2,952.31 $2,804.69 $3,225.3933414 $1,976.31 $1,877.49 $2,159.1133415 $1,818.33 $1,727.41 $1,986.5233416 $1,849.30 $1,756.84 $2,020.3733417 $1,576.39 $1,497.57 $1,722.2133420 $1,252.76 $1,190.12 $1,368.6433422 $1,589.88 $1,510.39 $1,736.9533425 $2,314.19 $2,198.48 $2,528.2533426 $2,205.94 $2,095.64 $2,409.9933427 $2,350.17 $2,232.66 $2,567.5633430 $2,495.72 $2,370.93 $2,726.5733460 $2,051.50 $1,948.93 $2,241.2733463 $2,562.18 $2,434.07 $2,799.1833464 $2,132.55 $2,025.92 $2,329.8133465 $2,347.27 $2,229.91 $2,564.4033468 $1,728.30 $1,641.89 $1,888.1733470 $1,104.15 $1,048.94 $1,206.2833471 $1,202.05 $1,141.95 $1,313.2433472 $1,259.17 $1,196.21 $1,375.6433474 $1,865.58 $1,772.30 $2,038.1533475 $2,125.55 $2,019.27 $2,322.1633476 $1,378.89 $1,309.95 $1,506.4433478 $1,484.82 $1,410.58 $1,622.1733496 $1,568.33 $1,489.91 $1,713.4033500 $1,459.56 $1,386.58 $1,594.5733501 $1,004.79 $954.55 $1,097.73

33502 $1,196.82 $1,136.98 $1,307.5333503 $1,154.39 $1,096.67 $1,261.1733504 $1,357.53 $1,289.65 $1,483.1033505 $1,809.20 $1,718.74 $1,976.5533506 $1,942.33 $1,845.21 $2,121.9933507 $1,647.32 $1,564.95 $1,799.6933508 $15.31 $14.54 $16.7233510 $1,858.84 $1,765.90 $2,030.7933511 $2,011.36 $1,910.79 $2,197.4133512 $2,232.03 $2,120.43 $2,438.4933513 $2,295.83 $2,181.04 $2,508.2033514 $2,398.05 $2,278.15 $2,619.8733516 $2,494.24 $2,369.53 $2,724.9633517 $166.80 $158.46 $182.2333518 $354.79 $337.05 $387.6133519 $477.54 $453.66 $521.7133521 $584.73 $555.49 $638.8133522 $674.01 $640.31 $736.3633523 $775.18 $736.42 $846.8833530 $448.97 $426.52 $490.5033533 $1,822.16 $1,731.05 $1,990.7133534 $2,085.45 $1,981.18 $2,278.3633535 $2,286.67 $2,172.34 $2,498.1933536 $2,437.90 $2,316.01 $2,663.4133542 $2,259.94 $2,146.94 $2,468.9833545 $2,681.16 $2,547.10 $2,929.1733548 $2,679.15 $2,545.19 $2,926.9733572 $220.68 $209.65 $241.1033600 $1,595.85 $1,516.06 $1,743.4733602 $1,550.23 $1,472.72 $1,693.6333606 $1,663.07 $1,579.92 $1,816.9133608 $1,708.08 $1,622.68 $1,866.0833610 $1,655.16 $1,572.40 $1,808.2633611 $1,817.82 $1,726.93 $1,985.9733612 $1,911.55 $1,815.97 $2,088.3733615 $1,800.01 $1,710.01 $1,966.5133617 $2,058.50 $1,955.58 $2,248.9233619 $2,550.38 $2,422.86 $2,786.2933641 $1,447.31 $1,374.94 $1,581.1833645 $1,469.64 $1,396.16 $1,605.5833647 $1,562.92 $1,484.77 $1,707.4933660 $1,668.57 $1,585.14 $1,822.9133665 $1,772.10 $1,683.50 $1,936.0333670 $1,837.37 $1,745.50 $2,007.3333675 $1,987.35 $1,887.98 $2,171.1833676 $2,049.58 $1,947.10 $2,239.1733677 $2,130.62 $2,024.09 $2,327.7033681 $1,726.31 $1,639.99 $1,885.9933684 $1,790.98 $1,701.43 $1,956.64

33688 $1,682.99 $1,598.84 $1,838.6733690 $1,083.09 $1,028.94 $1,183.2833692 $1,650.95 $1,568.40 $1,803.6633694 $1,829.32 $1,737.85 $1,998.5333697 $1,974.29 $1,875.58 $2,156.9233702 $1,460.26 $1,387.25 $1,595.3433710 $1,629.97 $1,548.47 $1,780.7433720 $1,456.26 $1,383.45 $1,590.9733722 $1,455.96 $1,383.16 $1,590.6333724 $1,427.87 $1,356.48 $1,559.9533726 $1,883.08 $1,788.93 $2,057.2733730 $1,863.36 $1,770.19 $2,035.7233732 $1,566.66 $1,488.33 $1,711.5833735 $1,120.73 $1,064.69 $1,224.3933736 $1,315.93 $1,250.13 $1,437.6533737 $1,208.97 $1,148.52 $1,320.8033750 $1,144.26 $1,087.05 $1,250.1133755 $1,161.22 $1,103.16 $1,268.6333762 $1,185.83 $1,126.54 $1,295.5233764 $1,200.67 $1,140.64 $1,311.7433766 $1,287.62 $1,223.24 $1,406.7333767 $1,359.49 $1,291.52 $1,485.2533768 $398.36 $378.44 $435.2133770 $1,980.61 $1,881.58 $2,163.8233771 $1,973.83 $1,875.14 $2,156.4133774 $1,709.74 $1,624.25 $1,867.8933775 $1,748.93 $1,661.48 $1,910.7033776 $1,857.70 $1,764.82 $2,029.5433777 $1,817.64 $1,726.76 $1,985.7733778 $2,213.64 $2,102.96 $2,418.4033779 $2,051.78 $1,949.19 $2,241.5733780 $2,197.25 $2,087.39 $2,400.5033781 $2,125.94 $2,019.64 $2,322.5933786 $2,131.02 $2,024.47 $2,328.1433788 $1,446.95 $1,374.60 $1,580.7933800 $935.65 $888.87 $1,022.2033802 $993.75 $944.06 $1,085.6733803 $1,107.53 $1,052.15 $1,209.9733813 $1,178.51 $1,119.58 $1,287.5233814 $1,435.33 $1,363.56 $1,568.0933820 $926.24 $879.93 $1,011.9233822 $966.39 $918.07 $1,055.7833824 $1,105.65 $1,050.37 $1,207.9333840 $1,130.30 $1,073.79 $1,234.8633845 $1,250.68 $1,188.15 $1,366.3733851 $1,197.03 $1,137.18 $1,307.7633852 $1,269.23 $1,205.77 $1,386.6433853 $1,735.82 $1,649.03 $1,896.3833860 $2,802.56 $2,662.43 $3,061.79

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

33861 $2,292.34 $2,177.72 $2,504.3833863 $2,860.51 $2,717.48 $3,125.1033870 $2,390.39 $2,270.87 $2,611.5033875 $1,845.31 $1,753.04 $2,016.0033877 $3,139.36 $2,982.39 $3,429.7533880 $1,695.32 $1,610.55 $1,852.1333881 $1,462.31 $1,389.19 $1,597.5733883 $1,075.96 $1,022.16 $1,175.4833884 $390.14 $370.63 $426.2233886 $933.01 $886.36 $1,019.3133889 $780.97 $741.92 $853.2133891 $1,001.66 $951.58 $1,094.3233910 $1,515.15 $1,439.39 $1,655.3033915 $1,216.67 $1,155.84 $1,329.2233916 $1,464.47 $1,391.25 $1,599.9433917 $1,375.01 $1,306.26 $1,502.2033920 $1,700.69 $1,615.66 $1,858.0133922 $1,296.15 $1,231.34 $1,416.0433924 $279.17 $265.21 $304.9933925 $1,674.70 $1,590.97 $1,829.6233926 $2,297.25 $2,182.39 $2,509.7533935 $3,326.08 $3,159.78 $3,633.7533945 $4,044.04 $3,841.84 $4,418.1233960 $919.38 $873.41 $1,004.4233961 $517.23 $491.37 $565.0833967 $243.83 $231.64 $266.3933968 $32.39 $30.77 $35.3933970 $336.09 $319.29 $367.1833971 $650.16 $617.65 $710.3033973 $490.82 $466.28 $536.2233974 $831.50 $789.93 $908.4233975 $1,031.50 $979.93 $1,126.9233976 $1,148.79 $1,091.35 $1,255.0533977 $1,135.83 $1,079.04 $1,240.9033978 $1,262.47 $1,199.35 $1,379.2533979 $2,295.72 $2,180.93 $2,508.0733980 $3,344.46 $3,177.24 $3,653.8334001 $892.82 $848.18 $975.4134051 $904.54 $859.31 $988.2134101 $588.87 $559.43 $643.3434111 $589.21 $559.75 $643.7134151 $1,355.32 $1,287.55 $1,480.6834201 $902.42 $857.30 $985.9034203 $941.63 $894.55 $1,028.7334401 $1,353.10 $1,285.45 $1,478.2734421 $707.16 $671.80 $772.5734451 $1,466.53 $1,393.20 $1,602.1834471 $953.45 $905.78 $1,041.6534490 $590.47 $560.95 $645.09

34501 $921.70 $875.62 $1,006.9634502 $1,471.58 $1,398.00 $1,607.7034510 $1,051.16 $998.60 $1,148.3934520 $1,016.65 $965.82 $1,110.6934530 $947.33 $899.96 $1,034.9534800 $1,106.92 $1,051.57 $1,209.3134802 $1,201.34 $1,141.27 $1,312.4634803 $1,236.01 $1,174.21 $1,350.3434804 $1,200.01 $1,140.01 $1,311.0134805 $1,141.33 $1,084.26 $1,246.9034808 $204.02 $193.82 $222.8934812 $339.68 $322.70 $371.1134813 $235.49 $223.72 $257.2834820 $484.31 $460.09 $529.1034825 $674.45 $640.73 $736.8434826 $199.36 $189.39 $217.8034830 $1,784.31 $1,695.09 $1,949.3534831 $1,850.89 $1,758.35 $2,022.1034832 $1,918.54 $1,822.61 $2,096.0034833 $604.51 $574.28 $660.4234834 $275.91 $262.11 $301.4334900 $881.84 $837.75 $963.4135001 $1,104.60 $1,049.37 $1,206.7835002 $1,164.11 $1,105.90 $1,271.7935005 $999.48 $949.51 $1,091.9435011 $971.08 $922.53 $1,060.9135013 $1,201.85 $1,141.76 $1,313.0235021 $1,159.35 $1,101.38 $1,266.5935022 $1,306.99 $1,241.64 $1,427.8935045 $937.69 $890.81 $1,024.4335081 $1,653.33 $1,570.66 $1,806.2635082 $2,106.92 $2,001.57 $2,301.8135091 $1,805.93 $1,715.63 $1,972.9735092 $2,516.78 $2,390.94 $2,749.5835102 $1,798.59 $1,708.66 $1,964.9635103 $2,185.45 $2,076.18 $2,387.6135111 $1,344.02 $1,276.82 $1,468.3435112 $1,631.95 $1,550.35 $1,782.9035121 $1,614.14 $1,533.43 $1,763.4435122 $1,895.35 $1,800.58 $2,070.6735131 $1,368.96 $1,300.51 $1,495.5935132 $1,648.04 $1,565.64 $1,800.4935141 $1,091.24 $1,036.68 $1,192.1835142 $1,297.28 $1,232.42 $1,417.2835151 $1,230.97 $1,169.42 $1,344.8335152 $1,421.85 $1,350.76 $1,553.3735180 $768.42 $730.00 $839.5035182 $1,643.37 $1,561.20 $1,795.3835184 $990.11 $940.60 $1,081.69

35188 $830.16 $788.65 $906.9535189 $1,537.95 $1,461.05 $1,680.2135190 $722.40 $686.28 $789.2235201 $907.95 $862.55 $991.9335206 $742.20 $705.09 $810.8535207 $661.20 $628.14 $722.3635211 $1,294.66 $1,229.93 $1,414.4235216 $1,674.68 $1,590.95 $1,829.5935221 $1,339.40 $1,272.43 $1,463.2935226 $823.44 $782.27 $899.6135231 $1,126.21 $1,069.90 $1,230.3935236 $946.45 $899.13 $1,034.0035241 $1,350.84 $1,283.30 $1,475.8035246 $1,477.66 $1,403.78 $1,614.3535251 $1,602.68 $1,522.55 $1,750.9335256 $1,001.15 $951.09 $1,093.7535261 $993.37 $943.70 $1,085.2635266 $831.84 $790.25 $908.7935271 $1,287.27 $1,222.91 $1,406.3535276 $1,356.41 $1,288.59 $1,481.8835281 $1,530.19 $1,453.68 $1,671.7335286 $917.16 $871.30 $1,002.0035301 $1,025.81 $974.52 $1,120.7035302 $1,064.64 $1,011.41 $1,163.1235303 $1,170.05 $1,111.55 $1,278.2835304 $1,217.58 $1,156.70 $1,330.2135305 $1,170.05 $1,111.55 $1,278.2835306 $440.09 $418.09 $480.8035311 $1,463.71 $1,390.52 $1,599.1035321 $874.40 $830.68 $955.2835331 $1,427.80 $1,356.41 $1,559.8735341 $1,361.47 $1,293.40 $1,487.4135351 $1,256.68 $1,193.85 $1,372.9335355 $1,022.03 $970.93 $1,116.5735361 $1,541.58 $1,464.50 $1,684.1835363 $1,648.87 $1,566.43 $1,801.3935371 $812.00 $771.40 $887.1135372 $974.42 $925.70 $1,064.5635390 $158.10 $150.20 $172.7335400 $150.99 $143.44 $164.9635450 $501.06 $476.01 $547.4135452 $350.15 $332.64 $382.5435454 $308.12 $292.71 $336.6235456 $373.65 $354.97 $408.2235458 $477.35 $453.48 $521.5035459 $435.35 $413.58 $475.6235460 $305.44 $290.17 $333.7035470 $3,068.86 $2,915.42 $3,352.73

# 35470 $430.13 $408.62 $469.91

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

35471 $3,447.55 $3,275.17 $3,766.45# 35471 $503.92 $478.72 $550.53

35472 $2,275.55 $2,161.77 $2,486.04# 35472 $347.23 $329.87 $379.35

35473 $2,120.44 $2,014.42 $2,316.58# 35473 $304.19 $288.98 $332.33

35474 $2,985.31 $2,836.04 $3,261.45# 35474 $367.11 $348.75 $401.06

35475 $2,159.52 $2,051.54 $2,359.27# 35475 $461.05 $438.00 $503.70

35476 $1,645.31 $1,563.04 $1,797.50# 35476 $292.80 $278.16 $319.88

35480 $555.39 $527.62 $606.7635481 $390.46 $370.94 $426.5835482 $338.38 $321.46 $369.6835483 $413.86 $393.17 $452.1535484 $518.27 $492.36 $566.2135485 $482.71 $458.57 $527.3635490 $572.73 $544.09 $625.7035491 $400.34 $380.32 $437.3735492 $351.64 $334.06 $384.1735493 $425.48 $404.21 $464.8435494 $530.93 $504.38 $580.0435495 $496.03 $471.23 $541.9135500 $315.73 $299.94 $344.9335501 $1,435.00 $1,363.25 $1,567.7435506 $1,265.55 $1,202.27 $1,382.6135508 $1,293.41 $1,228.74 $1,413.0535509 $1,395.56 $1,325.78 $1,524.6535510 $1,220.82 $1,159.78 $1,333.7535511 $1,147.99 $1,090.59 $1,254.1835512 $1,197.04 $1,137.19 $1,307.7735515 $1,283.65 $1,219.47 $1,402.3935516 $1,136.57 $1,079.74 $1,241.7035518 $1,159.78 $1,101.79 $1,267.0635521 $1,238.93 $1,176.98 $1,353.5335522 $1,165.25 $1,106.99 $1,273.0435525 $1,103.15 $1,047.99 $1,205.1935526 $1,663.69 $1,580.51 $1,817.5935531 $1,966.86 $1,868.52 $2,148.8035533 $1,523.28 $1,447.12 $1,664.1935536 $1,714.62 $1,628.89 $1,873.2235537 $2,058.70 $1,955.77 $2,249.1435538 $2,300.30 $2,185.29 $2,513.0835539 $2,162.05 $2,053.95 $2,362.0435540 $2,410.57 $2,290.04 $2,633.5535548 $1,172.59 $1,113.96 $1,281.0535549 $1,278.52 $1,214.59 $1,396.7835551 $1,442.72 $1,370.58 $1,576.17

35556 $1,330.69 $1,264.16 $1,453.7835558 $1,192.75 $1,133.11 $1,303.0835560 $1,740.29 $1,653.28 $1,901.2735563 $1,340.97 $1,273.92 $1,465.0135565 $1,289.14 $1,224.68 $1,408.3835566 $1,598.54 $1,518.61 $1,746.4035571 $1,324.24 $1,258.03 $1,446.7335572 $337.30 $320.44 $368.5135583 $1,378.57 $1,309.64 $1,506.0935585 $1,627.42 $1,546.05 $1,777.9635587 $1,368.24 $1,299.83 $1,494.8035600 $246.46 $234.14 $269.2635601 $1,349.74 $1,282.25 $1,474.5935606 $1,143.93 $1,086.73 $1,249.7435612 $891.70 $847.12 $974.1935616 $1,078.44 $1,024.52 $1,178.2035621 $1,089.01 $1,034.56 $1,189.7435623 $1,331.82 $1,265.23 $1,455.0135626 $1,514.73 $1,438.99 $1,654.8435631 $1,830.65 $1,739.12 $1,999.9935636 $1,607.94 $1,527.54 $1,756.6735637 $1,637.71 $1,555.82 $1,789.1935638 $1,663.66 $1,580.48 $1,817.5535642 $1,002.09 $951.99 $1,094.7935645 $978.54 $929.61 $1,069.0535646 $1,688.56 $1,604.13 $1,844.7535647 $1,521.92 $1,445.82 $1,662.6935650 $1,043.02 $990.87 $1,139.5035651 $1,341.95 $1,274.85 $1,466.0835654 $1,350.40 $1,282.88 $1,475.3135656 $1,064.71 $1,011.47 $1,163.1935661 $1,066.45 $1,013.13 $1,165.1035663 $1,234.81 $1,173.07 $1,349.0335665 $1,159.78 $1,101.79 $1,267.0635666 $1,249.21 $1,186.75 $1,364.7635671 $1,099.30 $1,044.34 $1,200.9935681 $79.07 $75.12 $86.3935682 $354.59 $336.86 $387.3935683 $418.40 $397.48 $457.1035685 $199.31 $189.34 $217.7435686 $165.04 $156.79 $180.3135691 $975.78 $926.99 $1,066.0435693 $852.92 $810.27 $931.8135694 $1,016.41 $965.59 $1,110.4335695 $1,043.26 $991.10 $1,139.7735697 $148.30 $140.89 $162.0235700 $152.29 $144.68 $166.3835701 $513.64 $487.96 $561.1535721 $438.83 $416.89 $479.42

35741 $481.78 $457.69 $526.3435761 $354.55 $336.82 $387.3435800 $454.93 $432.18 $497.0135820 $1,612.60 $1,531.97 $1,761.7735840 $589.65 $560.17 $644.2035860 $385.82 $366.53 $421.5135870 $1,247.18 $1,184.82 $1,362.5435875 $577.29 $548.43 $630.6935876 $925.84 $879.55 $1,011.4835879 $910.63 $865.10 $994.8735881 $1,015.57 $964.79 $1,109.5135883 $1,194.29 $1,134.58 $1,304.7735884 $1,268.61 $1,205.18 $1,385.9635901 $489.88 $465.39 $535.2035903 $559.96 $531.96 $611.7535905 $1,709.15 $1,623.69 $1,867.2435907 $1,882.15 $1,788.04 $2,056.2536000 $24.57 $23.34 $26.84

# 36000 $8.08 $7.68 $8.8336002 $162.56 $154.43 $177.59

# 36002 $103.33 $98.16 $112.8836005 $296.37 $281.55 $323.78

# 36005 $44.65 $42.42 $48.7836010 $667.49 $634.12 $729.24

# 36010 $115.58 $109.80 $126.2736011 $978.06 $929.16 $1,068.53

# 36011 $150.54 $143.01 $164.4636012 $769.86 $731.37 $841.08

# 36012 $166.80 $158.46 $182.2336013 $793.67 $753.99 $867.09

# 36013 $119.94 $113.94 $131.0336014 $769.69 $731.21 $840.89

# 36014 $143.41 $136.24 $156.6836015 $871.84 $828.25 $952.49

# 36015 $164.45 $156.23 $179.6636100 $510.20 $484.69 $557.39

# 36100 $150.12 $142.61 $164.0036120 $419.55 $398.57 $458.36

# 36120 $94.46 $89.74 $103.2036140 $482.81 $458.67 $527.47

# 36140 $95.80 $91.01 $104.6636145 $471.72 $448.13 $515.35

# 36145 $93.80 $89.11 $102.4836160 $531.85 $505.26 $581.05

# 36160 $122.29 $116.18 $133.6136200 $639.44 $607.47 $698.59

# 36200 $144.74 $137.50 $158.1336215 $1,063.01 $1,009.86 $1,161.34

# 36215 $223.70 $212.52 $244.40

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

36216 $1,151.44 $1,093.87 $1,257.95# 36216 $251.22 $238.66 $274.46

36217 $2,001.00 $1,900.95 $2,186.09# 36217 $302.20 $287.09 $330.15

36218 $195.66 $185.88 $213.76# 36218 $48.26 $45.85 $52.73

36245 $1,218.47 $1,157.55 $1,331.18# 36245 $229.41 $217.94 $250.63

36246 $1,174.30 $1,115.59 $1,282.93# 36246 $254.23 $241.52 $277.75

36247 $1,852.92 $1,760.27 $2,024.31# 36247 $303.20 $288.04 $331.25

36248 $165.04 $156.79 $180.31# 36248 $48.60 $46.17 $53.10

36260 $541.55 $514.47 $591.6436261 $331.58 $315.00 $362.2536262 $247.83 $235.44 $270.7636400 $23.65 $22.47 $25.84

# 36400 $17.25 $16.39 $18.8536405 $20.70 $19.67 $22.62

# 36405 $14.30 $13.59 $15.6336406 $16.16 $15.35 $17.65

# 36406 $8.42 $8.00 $9.2036410 $16.49 $15.67 $18.02

# 36410 $8.08 $7.68 $8.8336420 $45.57 $43.29 $49.7836425 $35.17 $33.41 $38.4236430 $35.32 $33.55 $38.58

# 36430 $27.58 $26.20 $30.1336440 $49.69 $47.21 $54.2936450 $107.74 $102.35 $117.7036455 $119.97 $113.97 $131.0736460 $321.37 $305.30 $351.1036470 $129.31 $122.84 $141.27

# 36470 $65.04 $61.79 $71.0636471 $159.85 $151.86 $174.64

# 36471 $91.87 $87.28 $100.3736475 $1,842.11 $1,750.00 $2,012.50

# 36475 $321.67 $305.59 $351.4336476 $369.91 $351.41 $404.12

# 36476 $157.56 $149.68 $172.1336478 $1,683.27 $1,599.11 $1,838.98

# 36478 $322.34 $306.22 $352.1536479 $376.64 $357.81 $411.48

# 36479 $158.23 $150.32 $172.8736481 $339.13 $322.17 $370.5036500 $170.85 $162.31 $186.6636510 $147.83 $140.44 $161.51

# 36510 $58.65 $55.72 $64.08

36511 $85.01 $80.76 $92.8736512 $85.68 $81.40 $93.6136513 $87.67 $83.29 $95.7836514 $577.69 $548.81 $631.13

# 36514 $84.34 $80.12 $92.1436515 $2,111.93 $2,006.33 $2,307.28

# 36515 $82.99 $78.84 $90.6736516 $2,580.78 $2,451.74 $2,819.50

# 36516 $59.84 $56.85 $65.3836522 $1,172.40 $1,113.78 $1,280.85

# 36522 $92.82 $88.18 $101.4136550 $24.79 $23.55 $27.08

# 36550 $22.77 $21.63 $24.8736555 $274.71 $260.97 $300.12

# 36555 $120.58 $114.55 $131.7336556 $257.52 $244.64 $281.34

# 36556 $115.16 $109.40 $125.8136557 $847.22 $804.86 $925.59

# 36557 $279.15 $265.19 $304.9736558 $834.96 $793.21 $912.19

# 36558 $265.89 $252.60 $290.4936560 $1,155.81 $1,098.02 $1,262.72

# 36560 $329.97 $313.47 $360.4936561 $1,153.87 $1,096.18 $1,260.61

# 36561 $319.95 $303.95 $349.5436563 $1,106.76 $1,051.42 $1,209.13

# 36563 $337.12 $320.26 $368.3036565 $994.35 $944.63 $1,086.32

# 36565 $319.27 $303.31 $348.8136566 $1,828.50 $1,737.08 $1,997.64

# 36566 $341.71 $324.62 $373.3136568 $305.81 $290.52 $334.10

# 36568 $88.41 $83.99 $96.5936569 $288.92 $274.47 $315.64

# 36569 $87.67 $83.29 $95.7836570 $1,225.94 $1,164.64 $1,339.34

# 36570 $288.37 $273.95 $315.0436571 $1,243.40 $1,181.23 $1,358.41

# 36571 $288.33 $273.91 $315.0036575 $158.64 $150.71 $173.32

# 36575 $37.82 $35.93 $41.3236576 $338.98 $322.03 $370.33

# 36576 $175.09 $166.34 $191.2936578 $480.12 $456.11 $524.53

# 36578 $199.46 $189.49 $217.9136580 $258.36 $245.44 $282.26

# 36580 $64.85 $61.61 $70.8536581 $740.68 $703.65 $809.20

# 36581 $185.40 $176.13 $202.55

36582 $1,008.91 $958.46 $1,102.23# 36582 $274.94 $261.19 $300.37

36583 $1,011.10 $960.55 $1,104.63# 36583 $277.46 $263.59 $303.13

36584 $254.57 $241.84 $278.12# 36584 $65.44 $62.17 $71.50

36585 $1,055.17 $1,002.41 $1,152.77# 36585 $257.59 $244.71 $281.42

36589 $157.00 $149.15 $171.52# 36589 $130.41 $123.89 $142.47

36590 $243.08 $230.93 $265.57# 36590 $184.52 $175.29 $201.58

36595 $651.03 $618.48 $711.25# 36595 $176.19 $167.38 $192.49

36596 $140.81 $133.77 $153.84# 36596 $42.88 $40.74 $46.85

36597 $120.37 $114.35 $131.50# 36597 $58.11 $55.20 $63.48

36598 $111.86 $106.27 $122.21# 36598 $95.71 $90.92 $104.56

36600 $28.15 $26.74 $30.75# 36600 $14.69 $13.96 $16.05

36620 $48.77 $46.33 $53.2836625 $98.18 $93.27 $107.2636640 $112.62 $106.99 $123.0436660 $65.21 $61.95 $71.2436680 $59.74 $56.75 $65.2636800 $149.89 $142.40 $163.7636810 $203.77 $193.58 $222.6236815 $139.47 $132.50 $152.3836818 $658.67 $625.74 $719.6036819 $760.37 $722.35 $830.7036820 $761.05 $723.00 $831.4536821 $504.02 $478.82 $550.6436822 $356.67 $338.84 $389.6736823 $1,184.65 $1,125.42 $1,294.2336825 $549.61 $522.13 $600.4536830 $631.87 $600.28 $690.3236831 $436.09 $414.29 $476.4336832 $557.21 $529.35 $608.7536833 $629.34 $597.87 $687.5536834 $581.78 $552.69 $635.5936835 $427.52 $406.14 $467.0636838 $1,133.17 $1,076.51 $1,237.9936860 $144.95 $137.70 $158.36

# 36860 $94.81 $90.07 $103.5836861 $142.82 $135.68 $156.0336870 $1,853.06 $1,760.41 $2,024.47

# 36870 $286.52 $272.19 $313.02

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

37140 $1,262.36 $1,199.24 $1,379.1337145 $1,349.64 $1,282.16 $1,474.4837160 $1,184.18 $1,124.97 $1,293.7237180 $1,337.50 $1,270.63 $1,461.2237181 $1,433.13 $1,361.47 $1,565.6937182 $807.53 $767.15 $882.2237183 $385.41 $366.14 $421.0637184 $2,521.87 $2,395.78 $2,755.15

# 37184 $421.59 $400.51 $460.5937185 $825.85 $784.56 $902.24

# 37185 $154.81 $147.07 $169.1337186 $1,699.00 $1,614.05 $1,856.16

# 37186 $232.40 $220.78 $253.9037187 $2,451.49 $2,328.92 $2,678.26

# 37187 $391.59 $372.01 $427.8137188 $2,111.55 $2,005.97 $2,306.87

# 37188 $282.85 $268.71 $309.0237200 $213.14 $202.48 $232.8537201 $262.94 $249.79 $287.2637202 $312.95 $297.30 $341.9037203 $1,253.11 $1,190.45 $1,369.02

# 37203 $247.22 $234.86 $270.0937204 $860.21 $817.20 $939.7837205 $428.84 $407.40 $468.5137206 $200.07 $190.07 $218.5837207 $421.26 $400.20 $460.2337208 $204.02 $193.82 $222.8937209 $106.54 $101.21 $116.3937210 $1,930.22 $1,833.71 $2,108.77

# 37210 $486.51 $462.18 $531.5137215 $1,018.05 $967.15 $1,112.2237250 $104.54 $99.31 $114.2137251 $79.08 $75.13 $86.4037500 $663.14 $629.98 $724.4837565 $637.27 $605.41 $696.2237600 $675.66 $641.88 $738.1637605 $771.42 $732.85 $842.7837606 $494.29 $469.58 $540.0237607 $355.20 $337.44 $388.0637609 $264.17 $250.96 $288.60

# 37609 $180.04 $171.04 $196.7037615 $423.33 $402.16 $462.4837616 $992.15 $942.54 $1,083.9237617 $1,205.19 $1,144.93 $1,316.6737618 $344.56 $327.33 $376.4337620 $607.59 $577.21 $663.7937650 $473.65 $449.97 $517.4737660 $1,135.66 $1,078.88 $1,240.7137700 $236.63 $224.80 $258.52

37718 $376.86 $358.02 $411.7237722 $447.22 $424.86 $488.5937735 $595.75 $565.96 $650.8537760 $585.20 $555.94 $639.3337765 $422.71 $401.57 $461.8137766 $511.29 $485.73 $558.5937780 $242.44 $230.32 $264.8737785 $322.20 $306.09 $352.00

# 37785 $240.42 $228.40 $262.6637788 $1,198.15 $1,138.24 $1,308.9837790 $458.50 $435.58 $500.9238100 $941.31 $894.24 $1,028.3838101 $958.10 $910.20 $1,046.7338102 $236.51 $224.68 $258.3838115 $1,044.07 $991.87 $1,140.6538120 $898.01 $853.11 $981.0838200 $125.11 $118.85 $136.6838205 $75.03 $71.28 $81.9738206 $75.03 $71.28 $81.9738220 $154.87 $147.13 $169.20

# 38220 $55.25 $52.49 $60.3638221 $171.45 $162.88 $187.31

# 38221 $70.15 $66.64 $76.6438230 $284.72 $270.48 $311.0538240 $113.83 $108.14 $124.3638241 $114.17 $108.46 $124.7338242 $86.61 $82.28 $94.6238300 $224.68 $213.45 $245.47

# 38300 $152.32 $144.70 $166.4138305 $393.23 $373.57 $429.6138308 $381.81 $362.72 $417.1338380 $491.98 $467.38 $537.4938381 $740.51 $703.48 $809.0038382 $594.97 $565.22 $650.0038500 $268.95 $255.50 $293.83

# 38500 $214.10 $203.40 $233.9138505 $110.69 $105.16 $120.93

# 38505 $67.28 $63.92 $73.5138510 $435.90 $414.11 $476.23

# 38510 $365.23 $346.97 $399.0238520 $398.14 $378.23 $434.9638525 $355.14 $337.38 $387.9938530 $464.31 $441.09 $507.2538542 $372.02 $353.42 $406.4338550 $402.00 $381.90 $439.1938555 $860.96 $817.91 $940.6038562 $606.35 $576.03 $662.4338564 $605.02 $574.77 $660.9938570 $488.07 $463.67 $533.22

38571 $740.27 $703.26 $808.7538572 $869.08 $825.63 $949.4738700 $664.02 $630.82 $725.4438720 $1,095.15 $1,040.39 $1,196.4538724 $1,183.20 $1,124.04 $1,292.6538740 $571.35 $542.78 $624.2038745 $729.58 $693.10 $797.0738746 $243.22 $231.06 $265.7238747 $240.55 $228.52 $262.8038760 $722.00 $685.90 $788.7938765 $1,120.26 $1,064.25 $1,223.8938770 $726.66 $690.33 $793.8838780 $936.04 $889.24 $1,022.6338790 $73.54 $69.86 $80.3438792 $34.96 $33.21 $38.1938794 $275.59 $261.81 $301.0839000 $438.90 $416.96 $479.5039010 $747.47 $710.10 $816.6239200 $823.09 $781.94 $899.2339220 $1,049.85 $997.36 $1,146.9639400 $457.70 $434.82 $500.0439501 $745.39 $708.12 $814.3439502 $890.76 $846.22 $973.1539503 $5,171.74 $4,913.15 $5,650.1239520 $902.80 $857.66 $986.3139530 $857.18 $814.32 $936.4739531 $903.08 $857.93 $986.6239540 $758.87 $720.93 $829.0739541 $816.41 $775.59 $891.9339545 $809.25 $768.79 $884.1139560 $700.57 $665.54 $765.3739561 $1,069.09 $1,015.64 $1,167.9940490 $102.25 $97.14 $111.71

# 40490 $63.88 $60.69 $69.7940500 $400.46 $380.44 $437.51

# 40500 $306.23 $290.92 $334.5640510 $399.89 $379.90 $436.89

# 40510 $308.69 $293.26 $337.2540520 $426.39 $405.07 $465.83

# 40520 $313.65 $297.97 $342.6740525 $491.50 $466.93 $536.9740527 $581.67 $552.59 $635.4840530 $463.17 $440.01 $506.01

# 40530 $354.47 $336.75 $387.2640650 $359.93 $341.93 $393.22

# 40650 $248.20 $235.79 $271.1640652 $419.52 $398.54 $458.32

# 40652 $306.44 $291.12 $334.7940654 $488.43 $464.01 $533.61

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 40654 $367.28 $348.92 $401.2640700 $814.93 $774.18 $890.3140701 $1,017.91 $967.01 $1,112.0640702 $791.08 $751.53 $864.2640720 $882.84 $838.70 $964.5140761 $934.95 $888.20 $1,021.4340800 $151.90 $144.31 $165.96

# 40800 $105.46 $100.19 $115.2240801 $240.23 $228.22 $262.45

# 40801 $188.74 $179.30 $206.2040804 $162.60 $154.47 $177.64

# 40804 $108.08 $102.68 $118.0840805 $259.71 $246.72 $283.73

# 40805 $196.78 $186.94 $214.9840806 $78.24 $74.33 $85.48

# 40806 $28.77 $27.33 $31.4340808 $133.27 $126.61 $145.60

# 40808 $87.50 $83.13 $95.6040810 $152.45 $144.83 $166.55

# 40810 $105.68 $100.40 $115.4640812 $220.84 $209.80 $241.27

# 40812 $168.68 $160.25 $184.2940814 $303.12 $287.96 $331.15

# 40814 $260.05 $247.05 $284.1140816 $318.91 $302.96 $348.40

# 40816 $271.79 $258.20 $296.9340818 $278.89 $264.95 $304.69

# 40818 $231.44 $219.87 $252.8540819 $237.08 $225.23 $259.01

# 40819 $197.03 $187.18 $215.2640820 $190.36 $180.84 $207.97

# 40820 $133.49 $126.82 $145.8440830 $195.19 $185.43 $213.24

# 40830 $136.63 $129.80 $149.2740831 $257.82 $244.93 $281.67

# 40831 $195.56 $185.78 $213.6540840 $675.23 $641.47 $737.69

# 40840 $567.20 $538.84 $619.6740842 $679.94 $645.94 $742.83

# 40842 $560.47 $532.45 $612.3240843 $877.64 $833.76 $958.82

# 40843 $725.19 $688.93 $792.2740844 $1,154.34 $1,096.62 $1,261.11

# 40844 $997.85 $947.96 $1,090.1540845 $1,279.23 $1,215.27 $1,397.56

# 40845 $1,134.86 $1,078.12 $1,239.8441000 $128.52 $122.09 $140.40

# 41000 $95.88 $91.09 $104.7541005 $167.05 $158.70 $182.51

# 41005 $105.47 $100.20 $115.2341006 $289.04 $274.59 $315.78

# 41006 $226.78 $215.44 $247.7641007 $291.87 $277.28 $318.87

# 41007 $216.49 $205.67 $236.5241008 $293.86 $279.17 $321.05

# 41008 $234.63 $222.90 $256.3441009 $313.54 $297.86 $342.54

# 41009 $256.00 $243.20 $279.6841010 $153.85 $146.16 $168.08

# 41010 $90.92 $86.37 $99.3341015 $340.57 $323.54 $372.07

# 41015 $289.41 $274.94 $316.1841016 $351.40 $333.83 $383.90

# 41016 $298.57 $283.64 $326.1941017 $353.42 $335.75 $386.11

# 41017 $300.92 $285.87 $328.7541018 $407.76 $387.37 $445.48

# 41018 $349.88 $332.39 $382.2541100 $135.16 $128.40 $147.66

# 41100 $97.81 $92.92 $106.8641105 $133.36 $126.69 $145.69

# 41105 $96.68 $91.85 $105.6341108 $112.07 $106.47 $122.44

# 41108 $77.07 $73.22 $84.2041110 $160.96 $152.91 $175.85

# 41110 $111.15 $105.59 $121.4341112 $259.52 $246.54 $283.52

# 41112 $211.73 $201.14 $231.3141113 $286.86 $272.52 $313.40

# 41113 $237.39 $225.52 $259.3541114 $556.62 $528.79 $608.1141115 $184.68 $175.45 $201.77

# 41115 $127.47 $121.10 $139.2741116 $246.27 $233.96 $269.05

# 41116 $185.02 $175.77 $202.1441120 $896.52 $851.69 $979.4441130 $1,091.74 $1,037.15 $1,192.7241135 $1,835.33 $1,743.56 $2,005.0941140 $1,912.08 $1,816.48 $2,088.9541145 $2,361.14 $2,243.08 $2,579.5441150 $1,874.51 $1,780.78 $2,047.9041153 $2,019.07 $1,918.12 $2,205.8441155 $2,467.64 $2,344.26 $2,695.9041250 $172.90 $164.26 $188.90

# 41250 $115.02 $109.27 $125.6641251 $194.44 $184.72 $212.43

# 41251 $138.58 $131.65 $151.4041252 $246.56 $234.23 $269.36

# 41252 $184.98 $175.73 $202.0941500 $380.32 $361.30 $415.5041510 $383.62 $364.44 $419.1141520 $268.27 $254.86 $293.09

# 41520 $221.83 $210.74 $242.3541800 $150.64 $143.11 $164.58

# 41800 $95.45 $90.68 $104.2841805 $154.93 $147.18 $169.26

# 41805 $127.00 $120.65 $138.7541806 $245.56 $233.28 $268.27

# 41806 $210.90 $200.36 $230.4141822 $227.61 $216.23 $248.66

# 41822 $152.56 $144.93 $166.6741823 $334.41 $317.69 $365.34

# 41823 $272.15 $258.54 $297.3241825 $158.55 $150.62 $173.21

# 41825 $119.51 $113.53 $130.5641826 $194.29 $184.58 $212.27

# 41826 $165.01 $156.76 $180.2741827 $333.48 $316.81 $364.33

# 41827 $259.44 $246.47 $283.4441828 $251.36 $238.79 $274.61

# 41828 $209.63 $199.15 $229.0241830 $305.89 $290.60 $334.19

# 41830 $248.00 $235.60 $270.9441872 $285.26 $271.00 $311.65

# 41872 $224.01 $212.81 $244.7341874 $292.50 $277.88 $319.56

# 41874 $225.53 $214.25 $246.3942000 $130.92 $124.37 $143.03

# 42000 $87.84 $83.45 $95.9742100 $120.82 $114.78 $132.00

# 42100 $94.57 $89.84 $103.3242104 $154.69 $146.96 $169.00

# 42104 $114.30 $108.59 $124.8842106 $199.18 $189.22 $217.60

# 42106 $159.81 $151.82 $174.5942107 $364.94 $346.69 $398.69

# 42107 $297.30 $282.44 $324.8142120 $810.10 $769.60 $885.0442140 $189.99 $180.49 $207.56

# 42140 $129.75 $123.26 $141.7542145 $596.55 $566.72 $651.7342160 $205.80 $195.51 $224.84

# 42160 $139.17 $132.21 $152.0442180 $197.69 $187.81 $215.98

# 42180 $161.01 $152.96 $175.9042182 $276.01 $262.21 $301.54

# 42182 $241.01 $228.96 $263.30

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

42200 $792.40 $752.78 $865.7042205 $833.06 $791.41 $910.1242210 $952.78 $905.14 $1,040.9142215 $637.25 $605.39 $696.2042220 $493.88 $469.19 $539.5742225 $890.74 $846.20 $973.1342226 $850.16 $807.65 $928.8042227 $841.45 $799.38 $919.2942235 $680.18 $646.17 $743.1042260 $724.68 $688.45 $791.72

# 42260 $614.30 $583.59 $671.1342280 $127.71 $121.32 $139.52

# 42280 $95.40 $90.63 $104.2242281 $162.18 $154.07 $177.18

# 42281 $132.57 $125.94 $144.8342300 $167.57 $159.19 $183.07

# 42300 $130.89 $124.35 $143.0042305 $379.66 $360.68 $414.7842310 $133.53 $126.85 $145.88

# 42310 $108.29 $102.88 $118.3142320 $200.13 $190.12 $218.64

# 42320 $155.37 $147.60 $169.7442330 $188.85 $179.41 $206.32

# 42330 $142.75 $135.61 $155.9542335 $293.35 $278.68 $320.48

# 42335 $225.71 $214.42 $246.5842340 $377.66 $358.78 $412.60

# 42340 $298.57 $283.64 $326.1942400 $86.08 $81.78 $94.05

# 42400 $51.75 $49.16 $56.5342405 $254.87 $242.13 $278.45

# 42405 $201.02 $190.97 $219.6242408 $371.72 $353.13 $406.10

# 42408 $288.26 $273.85 $314.9342409 $262.84 $249.70 $287.16

# 42409 $195.88 $186.09 $214.0042410 $551.75 $524.16 $602.7842415 $1,001.10 $951.05 $1,093.7142420 $1,152.03 $1,094.43 $1,258.5942425 $757.87 $719.98 $827.9842426 $1,232.38 $1,170.76 $1,346.3742440 $410.71 $390.17 $448.7042450 $371.35 $352.78 $405.70

# 42450 $311.11 $295.55 $339.8842500 $353.97 $336.27 $386.71

# 42500 $297.77 $282.88 $325.3142505 $467.49 $444.12 $510.74

# 42505 $402.87 $382.73 $440.1442507 $441.34 $419.27 $482.16

42508 $623.13 $591.97 $680.7742509 $758.99 $721.04 $829.2042510 $554.30 $526.59 $605.5842550 $143.38 $136.21 $156.64

# 42550 $58.24 $55.33 $63.6342600 $400.72 $380.68 $437.78

# 42600 $312.55 $296.92 $341.4642650 $66.51 $63.18 $72.66

# 42650 $51.70 $49.12 $56.4942660 $87.76 $83.37 $95.88

# 42660 $69.25 $65.79 $75.6642665 $240.26 $228.25 $262.49

# 42665 $179.35 $170.38 $195.9442700 $150.61 $143.08 $164.54

# 42700 $116.29 $110.48 $127.0542720 $388.44 $369.02 $424.37

# 42720 $350.07 $332.57 $382.4642725 $712.58 $676.95 $778.4942800 $126.17 $119.86 $137.84

# 42800 $97.23 $92.37 $106.2342802 $209.51 $199.03 $228.88

# 42802 $122.01 $115.91 $133.3042804 $168.66 $160.23 $184.26

# 42804 $101.35 $96.28 $110.7242806 $191.50 $181.93 $209.22

# 42806 $120.16 $114.15 $131.2742808 $188.86 $179.42 $206.33

# 42808 $146.79 $139.45 $160.3742809 $144.60 $137.37 $157.98

# 42809 $111.95 $106.35 $122.3042810 $314.72 $298.98 $343.83

# 42810 $240.35 $228.33 $262.5842815 $477.01 $453.16 $521.1342820 $257.11 $244.25 $280.8942821 $270.11 $256.60 $295.0942825 $226.44 $215.12 $247.3942826 $222.23 $211.12 $242.7942830 $178.81 $169.87 $195.3542831 $193.15 $183.49 $211.0142835 $163.65 $155.47 $178.7942836 $213.43 $202.76 $233.1742842 $803.87 $763.68 $878.2342844 $1,166.49 $1,108.17 $1,274.4042845 $1,916.62 $1,820.79 $2,093.9142860 $160.97 $152.92 $175.8642870 $483.69 $459.51 $528.4442890 $1,154.88 $1,097.14 $1,261.7142892 $1,502.68 $1,427.55 $1,641.6842894 $1,943.66 $1,846.48 $2,123.45

42900 $311.36 $295.79 $340.1642950 $688.52 $654.09 $752.2042953 $893.83 $849.14 $976.5142955 $644.48 $612.26 $704.1042960 $149.23 $141.77 $163.0442961 $369.23 $350.77 $403.3942962 $457.80 $434.91 $500.1542970 $344.60 $327.37 $376.4842971 $404.07 $383.87 $441.4542972 $458.97 $436.02 $501.4243020 $479.74 $455.75 $524.1143030 $466.78 $443.44 $509.9643045 $1,180.84 $1,121.80 $1,290.0743100 $556.45 $528.63 $607.9243101 $916.25 $870.44 $1,001.0143107 $2,273.97 $2,160.27 $2,484.3143108 $3,528.50 $3,352.08 $3,854.8943112 $2,437.12 $2,315.26 $2,662.5543113 $3,485.05 $3,310.80 $3,807.4243116 $3,929.24 $3,732.78 $4,292.7043117 $2,221.09 $2,110.04 $2,426.5543118 $2,943.52 $2,796.34 $3,215.7943121 $2,375.07 $2,256.32 $2,594.7743122 $2,251.03 $2,138.48 $2,459.2543123 $3,538.54 $3,361.61 $3,865.8543124 $3,002.68 $2,852.55 $3,280.4343130 $702.91 $667.76 $767.9243135 $1,255.90 $1,193.11 $1,372.0843200 $192.47 $182.85 $210.28

# 43200 $93.53 $88.85 $102.1843201 $239.80 $227.81 $261.98

# 43201 $113.94 $108.24 $124.4843202 $252.50 $239.88 $275.86

# 43202 $101.40 $96.33 $110.7843204 $192.95 $183.30 $210.8043205 $194.05 $184.35 $212.0043215 $137.07 $130.22 $149.7543216 $140.69 $133.66 $153.71

# 43216 $125.55 $119.27 $137.1643217 $338.11 $321.20 $369.38

# 43217 $149.65 $142.17 $163.5043219 $150.62 $143.09 $164.5543220 $111.29 $105.73 $121.5943226 $122.94 $116.79 $134.3143227 $183.91 $174.71 $200.9243228 $194.29 $184.58 $212.2743231 $164.22 $156.01 $179.4143232 $229.65 $218.17 $250.9043234 $250.27 $237.76 $273.42

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 43234 $104.89 $99.65 $114.6043235 $262.48 $249.36 $286.76

# 43235 $125.17 $118.91 $136.7543236 $324.41 $308.19 $354.42

# 43236 $151.43 $143.86 $165.4443237 $208.57 $198.14 $227.8643238 $256.27 $243.46 $279.9843239 $299.96 $284.96 $327.70

# 43239 $148.52 $141.09 $162.2543240 $347.03 $329.68 $379.1343241 $135.02 $128.27 $147.5143242 $366.95 $348.60 $400.8943243 $231.67 $220.09 $253.1043244 $256.03 $243.23 $279.7143245 $163.84 $155.65 $179.0043246 $219.34 $208.37 $239.6343247 $174.02 $165.32 $190.1243248 $163.04 $154.89 $178.1243249 $150.67 $143.14 $164.6143250 $164.93 $156.68 $180.1843251 $189.34 $179.87 $206.8543255 $244.76 $232.52 $267.4043256 $220.73 $209.69 $241.1443257 $272.29 $258.68 $297.4843258 $230.91 $219.36 $252.2643259 $261.68 $248.60 $285.8943260 $300.89 $285.85 $328.7343261 $316.54 $300.71 $345.8243262 $371.62 $353.04 $406.0043263 $367.87 $349.48 $401.9043264 $446.34 $424.02 $487.6243265 $500.67 $475.64 $546.9943267 $370.94 $352.39 $405.2543268 $375.66 $356.88 $410.4143269 $412.43 $391.81 $450.5843271 $371.62 $353.04 $406.0043272 $372.29 $353.68 $406.7343280 $929.54 $883.06 $1,015.5243300 $555.75 $527.96 $607.1543305 $998.34 $948.42 $1,090.6843310 $1,377.00 $1,308.15 $1,504.3743312 $1,514.04 $1,438.34 $1,654.0943313 $2,444.37 $2,322.15 $2,670.4743314 $2,672.01 $2,538.41 $2,919.1743320 $1,188.12 $1,128.71 $1,298.0243324 $1,162.99 $1,104.84 $1,270.5743325 $1,144.73 $1,087.49 $1,250.6143326 $1,162.94 $1,104.79 $1,270.5143330 $1,124.30 $1,068.09 $1,228.30

43331 $1,206.60 $1,146.27 $1,318.2143340 $1,163.75 $1,105.56 $1,271.3943341 $1,256.54 $1,193.71 $1,372.7743350 $986.30 $936.99 $1,077.5443351 $1,155.60 $1,097.82 $1,262.4943352 $951.60 $904.02 $1,039.6243360 $2,039.43 $1,937.46 $2,228.0843361 $2,268.90 $2,155.46 $2,478.7843400 $1,287.29 $1,222.93 $1,406.3743401 $1,318.96 $1,253.01 $1,440.9643405 $1,260.62 $1,197.59 $1,377.2343410 $868.28 $824.87 $948.6043415 $1,492.63 $1,418.00 $1,630.7043420 $860.72 $817.68 $940.3343425 $1,288.84 $1,224.40 $1,408.0643450 $139.51 $132.53 $152.41

# 43450 $75.90 $72.11 $82.9343453 $261.17 $248.11 $285.33

# 43453 $82.13 $78.02 $89.7243456 $550.21 $522.70 $601.11

# 43456 $134.60 $127.87 $147.0543458 $338.37 $321.45 $369.67

# 43458 $158.33 $150.41 $172.9743460 $191.73 $182.14 $209.4643500 $651.14 $618.58 $711.3743501 $1,132.26 $1,075.65 $1,237.0043502 $1,288.97 $1,224.52 $1,408.2043510 $784.77 $745.53 $857.3643520 $600.68 $570.65 $656.2543600 $93.41 $88.74 $102.0543605 $696.73 $661.89 $761.1743610 $825.05 $783.80 $901.3743611 $1,023.24 $972.08 $1,117.8943620 $1,678.99 $1,595.04 $1,834.3043621 $1,885.02 $1,790.77 $2,059.3943622 $1,927.24 $1,830.88 $2,105.5143631 $1,234.36 $1,172.64 $1,348.5443632 $1,619.54 $1,538.56 $1,769.3443633 $1,554.00 $1,476.30 $1,697.7543634 $1,709.97 $1,624.47 $1,868.1443635 $101.33 $96.26 $110.7043640 $982.81 $933.67 $1,073.7243641 $996.54 $946.71 $1,088.7243644 $1,471.26 $1,397.70 $1,607.3643645 $1,583.92 $1,504.72 $1,730.4343651 $548.78 $521.34 $599.5443652 $653.95 $621.25 $714.4443653 $461.78 $438.69 $504.4943750 $243.34 $231.17 $265.85

43752 $36.75 $34.91 $40.1543760 $201.04 $190.99 $219.64

# 43760 $55.33 $52.56 $60.4443761 $110.28 $104.77 $120.49

# 43761 $94.47 $89.75 $103.2143770 $938.74 $891.80 $1,025.5743771 $1,073.80 $1,020.11 $1,173.1343772 $809.18 $768.72 $884.0343773 $1,074.13 $1,020.42 $1,173.4843774 $812.69 $772.06 $887.8743800 $782.28 $743.17 $854.6543810 $845.98 $803.68 $924.2343820 $1,061.85 $1,008.76 $1,160.0743825 $1,090.70 $1,036.17 $1,191.6043830 $574.07 $545.37 $627.1843831 $477.26 $453.40 $521.4143832 $887.08 $842.73 $969.1443840 $1,082.51 $1,028.38 $1,182.6443843 $1,062.06 $1,008.96 $1,160.3043845 $1,640.94 $1,558.89 $1,792.7243846 $1,372.04 $1,303.44 $1,498.9643847 $1,509.41 $1,433.94 $1,649.0343848 $1,633.15 $1,551.49 $1,784.2143850 $1,372.18 $1,303.57 $1,499.1143855 $1,432.23 $1,360.62 $1,564.7143860 $1,388.17 $1,318.76 $1,516.5743865 $1,453.10 $1,380.45 $1,587.5243870 $585.82 $556.53 $640.0143880 $1,359.55 $1,291.57 $1,485.3143886 $270.31 $256.79 $295.3143887 $255.96 $243.16 $279.6343888 $366.91 $348.56 $400.8444005 $923.29 $877.13 $1,008.7044010 $721.97 $685.87 $788.7544015 $129.04 $122.59 $140.9844020 $812.87 $772.23 $888.0644021 $819.27 $778.31 $895.0644025 $827.43 $786.06 $903.9744050 $787.99 $748.59 $860.8844055 $1,259.28 $1,196.32 $1,375.7744100 $99.84 $94.85 $109.0844110 $706.38 $671.06 $771.7244111 $828.82 $787.38 $905.4944120 $1,021.10 $970.05 $1,115.5644121 $218.68 $207.75 $238.9144125 $997.84 $947.95 $1,090.1444126 $2,061.72 $1,958.63 $2,252.4244127 $2,386.55 $2,267.22 $2,607.3044128 $219.01 $208.06 $239.27

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

44130 $1,036.06 $984.26 $1,131.9044139 $109.41 $103.94 $119.5344140 $1,142.63 $1,085.50 $1,248.3344141 $1,452.20 $1,379.59 $1,586.5344143 $1,400.19 $1,330.18 $1,529.7144144 $1,442.01 $1,369.91 $1,575.4044145 $1,432.87 $1,361.23 $1,565.4144146 $1,748.44 $1,661.02 $1,910.1744147 $1,541.09 $1,464.04 $1,683.6544150 $1,533.71 $1,457.02 $1,675.5744151 $1,756.98 $1,669.13 $1,919.5044155 $1,726.19 $1,639.88 $1,885.8644156 $1,904.33 $1,809.11 $2,080.4844157 $1,868.10 $1,774.70 $2,040.9144158 $1,916.63 $1,820.80 $2,093.9244160 $1,046.47 $994.15 $1,143.2744180 $784.66 $745.43 $857.2444186 $551.45 $523.88 $602.4644187 $931.55 $884.97 $1,017.7244188 $1,026.01 $974.71 $1,120.9244202 $1,183.34 $1,124.17 $1,292.8044203 $217.67 $206.79 $237.8144204 $1,326.76 $1,260.42 $1,449.4844205 $1,160.30 $1,102.29 $1,267.6344206 $1,498.23 $1,423.32 $1,636.8244207 $1,581.79 $1,502.70 $1,728.1144208 $1,717.16 $1,631.30 $1,876.0044210 $1,526.78 $1,450.44 $1,668.0144211 $1,882.71 $1,788.57 $2,056.8644212 $1,754.48 $1,666.76 $1,916.7744213 $172.42 $163.80 $188.3744227 $1,432.30 $1,360.69 $1,564.7944300 $704.17 $668.96 $769.3044310 $885.61 $841.33 $967.5344312 $488.64 $464.21 $533.8444314 $847.67 $805.29 $926.0844316 $1,173.14 $1,114.48 $1,281.6544320 $1,005.88 $955.59 $1,098.9344322 $795.16 $755.40 $868.7144340 $493.20 $468.54 $538.8244345 $879.25 $835.29 $960.5844346 $984.66 $935.43 $1,075.7444360 $135.36 $128.59 $147.8844361 $149.20 $141.74 $163.0044363 $179.49 $170.52 $196.1044364 $190.82 $181.28 $208.4744365 $170.41 $161.89 $186.1744366 $224.69 $213.46 $245.4844369 $229.15 $217.69 $250.34

44370 $247.02 $234.67 $269.8744372 $223.67 $212.49 $244.3644373 $178.48 $169.56 $194.9944376 $264.90 $251.66 $289.4144377 $279.05 $265.10 $304.8744378 $358.15 $340.24 $391.2844379 $376.60 $357.77 $411.4444380 $58.48 $55.56 $63.8944382 $69.75 $66.26 $76.2044383 $152.82 $145.18 $166.9644385 $192.68 $183.05 $210.51

# 44385 $93.74 $89.05 $102.4144386 $303.18 $288.02 $331.22

# 44386 $110.35 $104.83 $120.5544388 $284.64 $270.41 $310.97

# 44388 $145.65 $138.37 $159.1344389 $342.36 $325.24 $374.03

# 44389 $161.31 $153.24 $176.2344390 $387.38 $368.01 $423.21

# 44390 $193.87 $184.18 $211.8144391 $453.85 $431.16 $495.83

# 44391 $219.97 $208.97 $240.3244392 $369.49 $351.02 $403.67

# 44392 $193.49 $183.82 $211.3944393 $418.76 $397.82 $457.49

# 44393 $242.76 $230.62 $265.2144394 $431.72 $410.13 $471.65

# 44394 $224.42 $213.20 $245.1844397 $238.26 $226.35 $260.3044500 $23.06 $21.91 $25.2044602 $1,136.66 $1,079.83 $1,241.8044603 $1,295.90 $1,231.11 $1,415.7844604 $900.53 $855.50 $983.8344605 $1,112.68 $1,057.05 $1,215.6144615 $909.38 $863.91 $993.5044620 $720.67 $684.64 $787.3444625 $859.65 $816.67 $939.1744626 $1,380.65 $1,311.62 $1,508.3644640 $1,199.41 $1,139.44 $1,310.3644650 $1,245.97 $1,183.67 $1,361.2244660 $1,176.29 $1,117.48 $1,285.1044661 $1,344.05 $1,276.85 $1,468.3844680 $894.16 $849.45 $976.8744700 $875.56 $831.78 $956.5544701 $151.39 $143.82 $165.3944720 $236.72 $224.88 $258.6144721 $346.82 $329.48 $378.9044800 $638.44 $606.52 $697.5044820 $703.41 $668.24 $768.48

44850 $625.01 $593.76 $682.8244900 $629.29 $597.83 $687.5044901 $984.02 $934.82 $1,075.04

# 44901 $158.18 $150.27 $172.8144950 $545.22 $517.96 $595.6544955 $76.13 $72.32 $83.1744960 $725.13 $688.87 $792.2044970 $495.05 $470.30 $540.8545000 $333.13 $316.47 $363.9445005 $211.84 $201.25 $231.44

# 45005 $129.72 $123.23 $141.7145020 $426.08 $404.78 $465.5045100 $233.05 $221.40 $254.6145108 $286.93 $272.58 $313.4745110 $1,567.45 $1,489.08 $1,712.4445111 $918.75 $872.81 $1,003.7345112 $1,625.74 $1,544.45 $1,776.1245113 $1,660.17 $1,577.16 $1,813.7345114 $1,518.24 $1,442.33 $1,658.6845116 $1,368.02 $1,299.62 $1,494.5645119 $1,662.20 $1,579.09 $1,815.9545120 $1,326.66 $1,260.33 $1,449.3845121 $1,461.63 $1,388.55 $1,596.8345123 $932.35 $885.73 $1,018.5945126 $2,441.75 $2,319.66 $2,667.6145130 $913.93 $868.23 $998.4645135 $1,124.72 $1,068.48 $1,228.7545136 $1,554.41 $1,476.69 $1,698.1945150 $320.68 $304.65 $350.3545160 $830.18 $788.67 $906.9745170 $647.92 $615.52 $707.8545190 $552.13 $524.52 $603.2045300 $69.07 $65.62 $75.46

# 45300 $24.32 $23.10 $26.5745303 $651.52 $618.94 $711.78

# 45303 $28.27 $26.86 $30.8945305 $131.71 $125.12 $143.89

# 45305 $55.32 $52.55 $60.4345307 $140.21 $133.20 $153.18

# 45307 $52.37 $49.75 $57.2145308 $109.16 $103.70 $119.26

# 45308 $46.57 $44.24 $50.8845309 $178.57 $169.64 $195.09

# 45309 $104.20 $98.99 $113.8445315 $155.06 $147.31 $169.41

# 45315 $74.29 $70.58 $81.1745317 $146.69 $139.36 $160.26

# 45317 $78.38 $74.46 $85.6345320 $165.83 $157.54 $181.17

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 45320 $83.38 $79.21 $91.0945321 $63.65 $60.47 $69.5445327 $85.65 $81.37 $93.5845330 $113.67 $107.99 $124.19

# 45330 $53.10 $50.45 $58.0245331 $146.70 $139.37 $160.28

# 45331 $63.57 $60.39 $69.4545332 $239.66 $227.68 $261.83

# 45332 $95.29 $90.53 $104.1145333 $236.30 $224.49 $258.16

# 45333 $94.62 $89.89 $103.3745334 $141.63 $134.55 $154.7345335 $179.18 $170.22 $195.75

# 45335 $78.55 $74.62 $85.8145337 $123.02 $116.87 $134.4045338 $266.64 $253.31 $291.31

# 45338 $121.93 $115.83 $133.2045339 $251.16 $238.60 $274.39

# 45339 $161.98 $153.88 $176.9645340 $311.06 $295.51 $339.84

# 45340 $99.38 $94.41 $108.5745341 $134.39 $127.67 $146.8245342 $205.50 $195.23 $224.5145345 $149.74 $142.25 $163.5945355 $179.89 $170.90 $196.5445378 53 $113.67 $107.99 $124.1945378 $344.47 $327.25 $376.34

# 45378 53 $53.10 $50.45 $58.02# 45378 $188.66 $179.23 $206.11

45379 $434.38 $412.66 $474.56# 45379 $237.17 $225.31 $259.11

45380 $409.18 $388.72 $447.03# 45380 $225.44 $214.17 $246.30

45381 $397.20 $377.34 $433.94# 45381 $213.12 $202.46 $232.83

45382 $545.21 $517.95 $595.64# 45382 $287.09 $272.74 $313.65

45383 $487.64 $463.26 $532.75# 45383 $294.48 $279.76 $321.72

45384 $404.81 $384.57 $442.26# 45384 $237.55 $225.67 $259.52

45385 $461.98 $438.88 $504.71# 45385 $268.14 $254.73 $292.94

45386 $585.05 $555.80 $639.17# 45386 $232.37 $220.75 $253.86

45387 $301.04 $285.99 $328.8945391 $259.26 $246.30 $283.2545392 $326.02 $309.72 $356.1845395 $1,693.31 $1,608.64 $1,849.94

45397 $1,834.21 $1,742.50 $2,003.8845400 $984.43 $935.21 $1,075.4945402 $1,320.12 $1,254.11 $1,442.2345500 $411.57 $390.99 $449.6445505 $448.70 $426.27 $490.2145520 $87.21 $82.85 $95.28

# 45520 $33.03 $31.38 $36.0945540 $896.44 $851.62 $979.3645541 $759.07 $721.12 $829.2945550 $1,236.92 $1,175.07 $1,351.3345560 $601.22 $571.16 $656.8345562 $913.85 $868.16 $998.3845563 $1,354.74 $1,287.00 $1,480.0545800 $1,015.39 $964.62 $1,109.3145805 $1,175.93 $1,117.13 $1,284.7045820 $1,013.67 $962.99 $1,107.4445825 $1,236.15 $1,174.34 $1,350.4945900 $162.97 $154.82 $178.0445905 $138.35 $131.43 $151.1445910 $163.47 $155.30 $178.6045915 $262.34 $249.22 $286.60

# 45915 $187.63 $178.25 $204.9945990 $93.65 $88.97 $102.3246020 $196.54 $186.71 $214.72

# 46020 $177.02 $168.17 $193.4046030 $96.92 $92.07 $105.88

# 46030 $72.02 $68.42 $78.6846040 $393.44 $373.77 $429.84

# 46040 $323.78 $307.59 $353.7346045 $321.46 $305.39 $351.2046050 $136.84 $130.00 $149.50

# 46050 $75.59 $71.81 $82.5846060 $354.08 $336.38 $386.8446070 $171.19 $162.63 $187.0246080 $180.42 $171.40 $197.11

# 46080 $133.30 $126.64 $145.6446083 $136.97 $130.12 $149.64

# 46083 $84.81 $80.57 $92.6646200 $281.72 $267.63 $307.77

# 46200 $235.28 $223.52 $257.0546210 $282.60 $268.47 $308.74

# 46210 $198.13 $188.22 $216.4546211 $359.25 $341.29 $392.48

# 46211 $285.88 $271.59 $312.3346220 $142.27 $135.16 $155.43

# 46220 $92.80 $88.16 $101.3846221 $184.43 $175.21 $201.49

# 46221 $147.41 $140.04 $161.0546230 $205.32 $195.05 $224.31

# 46230 $142.05 $134.95 $155.1946250 $341.87 $324.78 $373.50

# 46250 $247.98 $235.58 $270.9246255 $386.62 $367.29 $422.38

# 46255 $283.31 $269.14 $309.5146257 $319.66 $303.68 $349.2346258 $353.24 $335.58 $385.9246260 $366.39 $348.07 $400.2846261 $413.87 $393.18 $452.1646262 $427.32 $405.95 $466.8446270 $358.13 $340.22 $391.25

# 46270 $283.42 $269.25 $309.6446275 $370.80 $352.26 $405.10

# 46275 $306.85 $291.51 $335.2446280 $354.25 $336.54 $387.0246285 $345.58 $328.30 $377.55

# 46285 $298.47 $283.55 $326.0846288 $420.47 $399.45 $459.3746320 $135.03 $128.28 $147.52

# 46320 $90.27 $85.76 $98.6246500 $144.88 $137.64 $158.29

# 46500 $101.13 $96.07 $110.4846505 $215.86 $205.07 $235.83

# 46505 $180.53 $171.50 $197.2346600 $70.21 $66.70 $76.71

# 46600 $30.50 $28.98 $33.3346604 $384.24 $365.03 $419.78

# 46604 $69.25 $65.79 $75.6646606 $158.88 $150.94 $173.58

# 46606 $45.47 $43.20 $49.6846608 $200.91 $190.86 $219.49

# 46608 $78.41 $74.49 $85.6646610 $186.40 $177.08 $203.64

# 46610 $71.30 $67.74 $77.9046611 $175.80 $167.01 $192.06

# 46611 $94.02 $89.32 $102.7246612 $263.92 $250.72 $288.33

# 46612 $121.90 $115.81 $133.1846614 $155.36 $147.59 $169.73

# 46614 $103.53 $98.35 $113.1046615 $184.12 $174.91 $201.15

# 46615 $137.67 $130.79 $150.4146700 $511.19 $485.63 $558.4746705 $406.59 $386.26 $444.2046706 $135.32 $128.55 $147.8346710 $887.34 $842.97 $969.4246712 $1,860.25 $1,767.24 $2,032.3346715 $409.11 $388.65 $446.9546716 $919.08 $873.13 $1,004.10

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

46730 $1,511.00 $1,435.45 $1,650.7746735 $1,778.76 $1,689.82 $1,943.2946740 $1,676.24 $1,592.43 $1,831.2946742 $2,032.64 $1,931.01 $2,220.6646744 $2,918.86 $2,772.92 $3,188.8646746 $3,270.28 $3,106.77 $3,572.7946748 $3,303.17 $3,138.01 $3,608.7146750 $623.03 $591.88 $680.6646751 $518.41 $492.49 $566.3646753 $467.46 $444.09 $510.7046754 $226.31 $214.99 $247.24

# 46754 $165.74 $157.45 $181.0746760 $887.70 $843.32 $969.8246761 $770.53 $732.00 $841.8046762 $738.09 $701.19 $806.3746900 $166.43 $158.11 $181.83

# 46900 $113.93 $108.23 $124.4646910 $176.39 $167.57 $192.71

# 46910 $107.40 $102.03 $117.3346916 $179.11 $170.15 $195.67

# 46916 $116.51 $110.68 $127.2846917 $373.93 $355.23 $408.51

# 46917 $109.41 $103.94 $119.5346922 $188.50 $179.08 $205.94

# 46922 $108.40 $102.98 $118.4346924 $403.26 $383.10 $440.57

# 46924 $150.53 $143.00 $164.4546934 $313.22 $297.56 $342.19

# 46934 $238.17 $226.26 $260.2046935 $209.12 $198.66 $228.46

# 46935 $130.38 $123.86 $142.4446936 $312.20 $296.59 $341.08

# 46936 $222.34 $211.22 $242.9046937 $201.76 $191.67 $220.42

# 46937 $143.54 $136.36 $156.8146938 $329.07 $312.62 $359.51

# 46938 $287.34 $272.97 $313.9246940 $161.29 $153.23 $176.21

# 46940 $123.60 $117.42 $135.0346942 $145.73 $138.44 $159.21

# 46942 $110.06 $104.56 $120.2446945 $201.93 $191.83 $220.60

# 46945 $166.60 $158.27 $182.0146946 $230.61 $219.08 $251.94

# 46946 $180.47 $171.45 $197.1746947 $306.79 $291.45 $335.1747000 $207.46 $197.09 $226.65

# 47000 $89.67 $85.19 $97.9747001 $93.67 $88.99 $102.34

47010 $997.46 $947.59 $1,089.7347011 $172.53 $163.90 $188.4947015 $941.85 $894.76 $1,028.9747100 $692.09 $657.49 $756.1147120 $1,979.17 $1,880.21 $2,162.2447122 $2,963.07 $2,814.92 $3,237.1647125 $2,655.36 $2,522.59 $2,900.9847130 $2,858.15 $2,715.24 $3,122.5347135 $4,200.51 $3,990.48 $4,589.0547136 $3,562.47 $3,384.35 $3,892.0047140 $2,936.58 $2,789.75 $3,208.2147141 $3,495.80 $3,321.01 $3,819.1647142 $3,848.17 $3,655.76 $4,204.1247146 $296.94 $282.09 $324.4047147 $346.49 $329.17 $378.5547300 $926.98 $880.63 $1,012.7247350 $1,147.00 $1,089.65 $1,253.1047360 $1,563.05 $1,484.90 $1,707.6447361 $2,592.93 $2,463.28 $2,832.7747362 $1,179.62 $1,120.64 $1,288.7447370 $1,059.79 $1,006.80 $1,157.8247371 $1,065.49 $1,012.22 $1,164.0547380 $1,235.91 $1,174.11 $1,350.2347381 $1,255.19 $1,192.43 $1,371.2947382 $745.89 $708.60 $814.8947400 $1,787.06 $1,697.71 $1,952.3747420 $1,128.12 $1,071.71 $1,232.4747425 $1,138.65 $1,081.72 $1,243.9847460 $1,056.22 $1,003.41 $1,153.9247480 $699.49 $664.52 $764.2047490 $467.75 $444.36 $511.0147500 $91.57 $86.99 $100.0447505 $35.18 $33.42 $38.4347510 $446.12 $423.81 $487.3847511 $550.66 $523.13 $601.6047525 $698.18 $663.27 $762.76

# 47525 $289.97 $275.47 $316.7947530 $1,311.21 $1,245.65 $1,432.50

# 47530 $334.27 $317.56 $365.1947550 $148.73 $141.29 $162.4847552 $296.81 $281.97 $324.2747553 $296.00 $281.20 $323.3847554 $449.54 $427.06 $491.1247555 $353.10 $335.45 $385.7747556 $398.97 $379.02 $435.8747560 $240.88 $228.84 $263.1747561 $259.48 $246.51 $283.4947562 $615.38 $584.61 $672.3047563 $639.09 $607.14 $698.21

47564 $743.22 $706.06 $811.9747570 $660.96 $627.91 $722.1047600 $866.61 $823.28 $946.7747605 $824.70 $783.47 $900.9947610 $1,058.09 $1,005.19 $1,155.9747612 $1,066.60 $1,013.27 $1,165.2647620 $1,159.13 $1,101.17 $1,266.3547630 $506.48 $481.16 $553.3347700 $875.67 $831.89 $956.6747701 $1,472.77 $1,399.13 $1,609.0047711 $1,310.99 $1,245.44 $1,432.2647712 $1,686.51 $1,602.18 $1,842.5147715 $1,098.03 $1,043.13 $1,199.6047719 $985.82 $936.53 $1,077.0147720 $944.54 $897.31 $1,031.9147721 $1,117.85 $1,061.96 $1,221.2547740 $1,082.69 $1,028.56 $1,182.8447741 $1,227.20 $1,165.84 $1,340.7247760 $1,797.92 $1,708.02 $1,964.2247765 $2,297.84 $2,182.95 $2,510.3947780 $1,954.52 $1,856.79 $2,135.3147785 $2,522.54 $2,396.41 $2,755.8747800 $1,326.13 $1,259.82 $1,448.7947801 $903.62 $858.44 $987.2147802 $1,264.62 $1,201.39 $1,381.6047900 $1,146.14 $1,088.83 $1,252.1548000 $1,582.31 $1,503.19 $1,728.6748001 $1,961.81 $1,863.72 $2,143.2848020 $965.55 $917.27 $1,054.8648100 $734.52 $697.79 $802.4648102 $445.18 $422.92 $486.36

# 48102 $231.14 $219.58 $252.5248105 $2,409.71 $2,289.22 $2,632.6048120 $925.82 $879.53 $1,011.4648140 $1,313.28 $1,247.62 $1,434.7648145 $1,365.10 $1,296.85 $1,491.3848146 $1,555.75 $1,477.96 $1,699.6548148 $1,027.00 $975.65 $1,122.0048150 $2,648.96 $2,516.51 $2,893.9948152 $2,444.40 $2,322.18 $2,670.5148153 $2,647.86 $2,515.47 $2,892.7948154 $2,457.40 $2,334.53 $2,684.7148155 $1,501.64 $1,426.56 $1,640.5448400 $94.54 $89.81 $103.2848500 $934.79 $888.05 $1,021.2648510 $893.43 $848.76 $976.0748511 $831.59 $790.01 $908.51

# 48511 $186.80 $177.46 $204.0848520 $910.68 $865.15 $994.92

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

48540 $1,102.00 $1,046.90 $1,203.9448545 $1,102.34 $1,047.22 $1,204.3048547 $1,496.25 $1,421.44 $1,634.6648548 $1,402.07 $1,331.97 $1,531.7748552 $203.44 $193.27 $222.2648554 $2,035.07 $1,933.32 $2,223.3248556 $1,007.68 $957.30 $1,100.9049000 $654.14 $621.43 $714.6449002 $824.43 $783.21 $900.6949010 $796.86 $757.02 $870.5749020 $1,336.90 $1,270.06 $1,460.5749021 $809.03 $768.58 $883.87

# 49021 $157.51 $149.63 $172.0749040 $832.79 $791.15 $909.8249041 $794.57 $754.84 $868.07

# 49041 $186.80 $177.46 $204.0849060 $934.01 $887.31 $1,020.4149061 $785.35 $746.08 $857.99

# 49061 $172.53 $163.90 $188.4949062 $640.16 $608.15 $699.3749080 $170.68 $162.15 $186.47

# 49080 $63.67 $60.49 $69.5649081 $135.01 $128.26 $147.50

# 49081 $60.30 $57.29 $65.8849180 $159.71 $151.72 $174.48

# 49180 $80.96 $76.91 $88.4549200 $581.86 $552.77 $635.6949201 $828.21 $786.80 $904.8249215 $1,891.38 $1,796.81 $2,066.3349220 $817.90 $777.01 $893.5649250 $484.03 $459.83 $528.8049255 $659.42 $626.45 $720.4249320 $282.41 $268.29 $308.5349321 $295.32 $280.55 $322.6349322 $324.40 $308.18 $354.4149323 $538.05 $511.15 $587.8249324 $332.32 $315.70 $363.0649325 $358.08 $340.18 $391.2149326 $165.01 $156.76 $180.2749400 $165.97 $157.67 $181.32

# 49400 $89.24 $84.78 $97.5049402 $716.96 $681.11 $783.2849419 $384.98 $365.73 $420.5949420 $120.15 $114.14 $131.2649421 $330.78 $314.24 $361.3849422 $335.94 $319.14 $367.0149423 $512.68 $487.05 $560.11

# 49423 $69.81 $66.32 $76.2749424 $145.23 $137.97 $158.67

# 49424 $36.53 $34.70 $39.9149425 $650.25 $617.74 $710.4049426 $552.92 $525.27 $604.0649427 $42.41 $40.29 $46.3349428 $383.09 $363.94 $418.5349429 $397.81 $377.92 $434.6149435 $106.08 $100.78 $115.9049436 $155.90 $148.11 $170.3349491 $643.32 $611.15 $702.8249492 $785.85 $746.56 $858.5449495 $333.86 $317.17 $364.7549496 $497.64 $472.76 $543.6749500 $329.02 $312.57 $359.4649501 $495.47 $470.70 $541.3149505 $430.25 $408.74 $470.0549507 $532.39 $505.77 $581.6449520 $529.10 $502.65 $578.0549521 $648.77 $616.33 $708.7849525 $476.99 $453.14 $521.1149540 $567.97 $539.57 $620.5149550 $480.23 $456.22 $524.6549553 $525.16 $498.90 $573.7449555 $500.25 $475.24 $546.5349557 $608.98 $578.53 $665.3149560 $625.26 $594.00 $683.1049561 $786.42 $747.10 $859.1749565 $644.12 $611.91 $703.7049566 $794.41 $754.69 $867.8949568 $240.55 $228.52 $262.8049570 $336.55 $319.72 $367.6849572 $414.81 $394.07 $453.1849580 $258.23 $245.32 $282.1249582 $387.40 $368.03 $423.2349585 $362.16 $344.05 $395.6649587 $431.23 $409.67 $471.1249590 $475.85 $452.06 $519.8749600 $613.15 $582.49 $669.8649605 $4,215.28 $4,004.52 $4,605.2049606 $976.76 $927.92 $1,067.1149610 $575.43 $546.66 $628.6649611 $548.33 $520.91 $599.0549650 $354.59 $336.86 $387.3949651 $458.37 $435.45 $500.7749900 $682.03 $647.93 $745.1249904 $1,332.97 $1,266.32 $1,456.2749905 $320.54 $304.51 $350.1950010 $634.28 $602.57 $692.9650020 $920.95 $874.90 $1,006.1450021 $835.95 $794.15 $913.27

# 50021 $157.51 $149.63 $172.0750040 $842.67 $800.54 $920.6250045 $847.70 $805.32 $926.1250060 $1,046.53 $994.20 $1,143.3350065 $1,061.44 $1,008.37 $1,159.6350070 $1,093.02 $1,038.37 $1,194.1350075 $1,344.64 $1,277.41 $1,469.0250080 $798.30 $758.39 $872.1550081 $1,171.83 $1,113.24 $1,280.2350100 $915.83 $870.04 $1,000.5550120 $867.37 $824.00 $947.6050125 $909.35 $863.88 $993.4650130 $943.85 $896.66 $1,031.1650135 $1,029.32 $977.85 $1,124.5350200 $136.88 $130.04 $149.5550205 $632.36 $600.74 $690.8550220 $941.29 $894.23 $1,028.3650225 $1,090.73 $1,036.19 $1,191.6250230 $1,175.92 $1,117.12 $1,284.6950234 $1,194.59 $1,134.86 $1,305.0950236 $1,349.06 $1,281.61 $1,473.8550240 $1,205.76 $1,145.47 $1,317.2950250 $1,119.97 $1,063.97 $1,223.5750280 $865.27 $822.01 $945.3150290 $824.91 $783.66 $901.2150320 $1,211.72 $1,151.13 $1,323.8050327 $189.51 $180.03 $207.0350328 $166.08 $157.78 $181.4550329 $158.71 $150.77 $173.3950340 $755.78 $717.99 $825.6950360 $2,055.32 $1,952.55 $2,245.4350365 $2,328.16 $2,211.75 $2,543.5150370 $951.16 $903.60 $1,039.1450380 $1,536.34 $1,459.52 $1,678.4550382 $1,319.58 $1,253.60 $1,441.64

# 50382 $259.84 $246.85 $283.8850384 $1,234.22 $1,172.51 $1,348.39

# 50384 $236.74 $224.90 $258.6450387 $632.88 $601.24 $691.43

# 50387 $94.09 $89.39 $102.8050389 $415.08 $394.33 $453.48

# 50389 $51.97 $49.37 $56.7850390 $91.57 $86.99 $100.0450391 $123.87 $117.68 $135.33

# 50391 $93.92 $89.22 $102.6050392 $170.63 $162.10 $186.4250393 $207.24 $196.88 $226.4150394 $109.89 $104.40 $120.06

# 50394 $48.64 $46.21 $53.14

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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50395 $171.30 $162.74 $187.1550396 $110.58 $105.05 $120.8150398 $559.46 $531.49 $611.21

# 50398 $69.81 $66.32 $76.2750400 $1,059.53 $1,006.55 $1,157.5350405 $1,275.02 $1,211.27 $1,392.9650500 $1,075.61 $1,021.83 $1,175.1050520 $955.81 $908.02 $1,044.2250525 $1,206.43 $1,146.11 $1,318.0350526 $1,273.64 $1,209.96 $1,391.4550540 $1,061.21 $1,008.15 $1,159.3750541 $847.06 $804.71 $925.4250542 $1,068.82 $1,015.38 $1,167.6950543 $1,365.22 $1,296.96 $1,491.5050544 $1,159.20 $1,101.24 $1,266.4350545 $1,243.56 $1,181.38 $1,358.5950546 $1,099.66 $1,044.68 $1,201.3850547 $1,373.77 $1,305.08 $1,500.8450548 $1,254.92 $1,192.17 $1,371.0050551 $347.33 $329.96 $379.45

# 50551 $276.32 $262.50 $301.8850553 $363.29 $345.13 $396.90

# 50553 $292.61 $277.98 $319.6850555 $401.65 $381.57 $438.81

# 50555 $321.56 $305.48 $351.3050557 $401.35 $381.28 $438.47

# 50557 $325.30 $309.04 $355.4050561 $453.15 $430.49 $495.06

# 50561 $372.04 $353.44 $406.4650562 $550.54 $523.01 $601.4650570 $464.91 $441.66 $507.9150572 $507.96 $482.56 $554.9450574 $535.43 $508.66 $584.9650575 $677.61 $643.73 $740.2950576 $534.00 $507.30 $583.4050580 $575.32 $546.55 $628.5350590 $807.93 $767.53 $882.66

# 50590 $506.74 $481.40 $553.6150592 $4,625.41 $4,394.14 $5,053.26

# 50592 $342.73 $325.59 $374.4350600 $859.95 $816.95 $939.4950605 $853.65 $810.97 $932.6250610 $884.72 $840.48 $966.5550620 $827.51 $786.13 $904.0550630 $813.19 $772.53 $888.4150650 $945.87 $898.58 $1,033.3750660 $1,050.48 $997.96 $1,147.6550684 $186.62 $177.29 $203.88

# 50684 $44.60 $42.37 $48.73

50686 $159.20 $151.24 $173.93# 50686 $81.79 $77.70 $89.36

50688 $76.50 $72.68 $83.5850690 $99.29 $94.33 $108.48

# 50690 $65.64 $62.36 $71.7150700 $856.65 $813.82 $935.8950715 $1,063.61 $1,010.43 $1,161.9950722 $934.95 $888.20 $1,021.4350725 $1,019.02 $968.07 $1,113.2850727 $455.38 $432.61 $497.5050728 $643.51 $611.33 $703.0350740 $1,016.40 $965.58 $1,110.4250750 $1,048.88 $996.44 $1,145.9150760 $1,007.78 $957.39 $1,101.0050770 $1,058.96 $1,006.01 $1,156.9150780 $1,002.95 $952.80 $1,095.7250782 $1,011.91 $961.31 $1,105.5150783 $1,058.40 $1,005.48 $1,156.3050785 $1,105.56 $1,050.28 $1,207.8250800 $835.29 $793.53 $912.5650810 $1,150.53 $1,093.00 $1,256.9550815 $1,115.21 $1,059.45 $1,218.3750820 $1,197.82 $1,137.93 $1,308.6250825 $1,517.36 $1,441.49 $1,657.7150830 $1,666.03 $1,582.73 $1,820.1450840 $1,119.78 $1,063.79 $1,223.3650845 $1,139.69 $1,082.71 $1,245.1250860 $864.18 $820.97 $944.1250900 $768.92 $730.47 $840.0450920 $804.53 $764.30 $878.9550930 $1,014.01 $963.31 $1,107.8150940 $810.98 $770.43 $885.9950945 $906.77 $861.43 $990.6450947 $1,296.57 $1,231.74 $1,416.5050948 $1,186.35 $1,127.03 $1,296.0850951 $361.68 $343.60 $395.14

# 50951 $287.64 $273.26 $314.2550953 $380.02 $361.02 $415.17

# 50953 $314.06 $298.36 $343.1150955 $451.62 $429.04 $493.40

# 50955 $342.92 $325.77 $374.6450957 $407.37 $387.00 $445.05

# 50957 $333.67 $316.99 $364.5450961 $369.89 $351.40 $404.11

# 50961 $297.87 $282.98 $325.4350970 $350.45 $332.93 $382.8750972 $338.76 $321.82 $370.0950974 $445.35 $423.08 $486.5450976 $438.10 $416.20 $478.63

50980 $335.23 $318.47 $366.2451000 $85.07 $80.82 $92.94

# 51000 $36.61 $34.78 $40.0051005 $177.19 $168.33 $193.58

# 51005 $49.31 $46.84 $53.8751010 $336.25 $319.44 $367.36

# 51010 $222.17 $211.06 $242.7251020 $415.73 $394.94 $454.1851030 $422.22 $401.11 $461.2851040 $262.47 $249.35 $286.7551045 $422.58 $401.45 $461.6751050 $422.30 $401.19 $461.3751060 $523.58 $497.40 $572.0151065 $519.54 $493.56 $567.5951080 $365.36 $347.09 $399.1551500 $582.17 $553.06 $636.0251520 $540.05 $513.05 $590.0151525 $782.27 $743.16 $854.6351530 $704.71 $669.47 $769.8951535 $728.26 $691.85 $795.6351550 $871.88 $828.29 $952.5351555 $1,157.89 $1,100.00 $1,265.0051565 $1,184.30 $1,125.09 $1,293.8551570 $1,347.87 $1,280.48 $1,472.5551575 $1,677.85 $1,593.96 $1,833.0551580 $1,738.02 $1,651.12 $1,898.7951585 $1,939.72 $1,842.73 $2,119.1451590 $1,775.19 $1,686.43 $1,939.3951595 $2,013.48 $1,912.81 $2,199.7351596 $2,159.08 $2,051.13 $2,358.8051597 $2,091.79 $1,987.20 $2,285.2851600 $193.81 $184.12 $211.74

# 51600 $41.70 $39.62 $45.5651605 $35.77 $33.98 $39.0851610 $111.32 $105.75 $121.61

# 51610 $58.82 $55.88 $64.2651700 $85.11 $80.85 $92.98

# 51700 $42.04 $39.94 $45.9351701 $67.18 $63.82 $73.39

# 51701 $25.45 $24.18 $27.8151702 $83.67 $79.49 $91.41

# 51702 $27.47 $26.10 $30.0251703 $141.53 $134.45 $154.62

# 51703 $74.56 $70.83 $81.4551705 $111.95 $106.35 $122.30

# 51705 $60.13 $57.12 $65.6951710 $161.85 $153.76 $176.82

# 51710 $84.44 $80.22 $92.2551715 $272.59 $258.96 $297.80

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 51715 $185.76 $176.47 $202.9451720 $113.71 $108.02 $124.22

# 51720 $79.72 $75.73 $87.0951725 26 $72.71 $69.07 $79.4351725 $233.89 $222.20 $255.5351725 TC $161.19 $153.13 $176.1051726 26 $82.55 $78.42 $90.1851726 TC $231.18 $219.62 $252.5651726 $313.73 $298.04 $342.7551736 26 $29.58 $28.10 $32.3251736 TC $15.81 $15.02 $17.2751736 $45.39 $43.12 $49.5951741 TC $18.17 $17.26 $19.8551741 26 $55.16 $52.40 $60.2651741 $73.33 $69.66 $80.1151772 $244.69 $232.46 $267.3351772 TC $166.23 $157.92 $181.6151772 26 $78.46 $74.54 $85.7251784 $190.56 $181.03 $208.1851784 TC $117.10 $111.25 $127.9451784 26 $73.46 $69.79 $80.2651785 $207.39 $197.02 $226.5751785 TC $133.93 $127.23 $146.3151785 26 $73.47 $69.80 $80.2751792 $237.36 $225.49 $259.3151792 26 $53.65 $50.97 $58.6251792 TC $183.71 $174.52 $200.7051795 $300.25 $285.24 $328.0351795 TC $226.45 $215.13 $247.4051795 26 $73.80 $70.11 $80.6351797 $247.02 $234.67 $269.8751797 TC $169.93 $161.43 $185.6451797 26 $77.08 $73.23 $84.2151798 $16.13 $15.32 $17.6251800 $959.22 $911.26 $1,047.9551820 $1,018.55 $967.62 $1,112.7651840 $609.14 $578.68 $665.4851841 $723.58 $687.40 $790.5151845 $539.31 $512.34 $589.1951860 $667.20 $633.84 $728.9251865 $816.04 $775.24 $891.5351880 $429.71 $408.22 $469.4551900 $754.88 $717.14 $824.7151920 $699.78 $664.79 $764.5151925 $963.79 $915.60 $1,052.9451940 $1,511.95 $1,436.35 $1,651.8051960 $1,268.16 $1,204.75 $1,385.4651980 $650.30 $617.79 $710.4651990 $703.76 $668.57 $768.86

51992 $762.99 $724.84 $833.5752000 $195.26 $185.50 $213.33

# 52000 $111.47 $105.90 $121.7952001 $369.62 $351.14 $403.81

# 52001 $267.65 $254.27 $292.4152005 $275.18 $261.42 $300.63

# 52005 $120.72 $114.68 $131.8852007 $615.55 $584.77 $672.49

# 52007 $153.49 $145.82 $167.6952010 $449.98 $427.48 $491.60

# 52010 $153.16 $145.50 $167.3352204 $530.45 $503.93 $579.52

# 52204 $128.63 $122.20 $140.5352214 $1,263.93 $1,200.73 $1,380.84

# 52214 $184.34 $175.12 $201.3952224 $1,194.81 $1,135.07 $1,305.33

# 52224 $157.28 $149.42 $171.8352234 $230.24 $218.73 $251.5452235 $270.01 $256.51 $294.9952240 $475.01 $451.26 $518.9552250 $225.36 $214.09 $246.2052260 $195.57 $185.79 $213.6652265 $508.87 $483.43 $555.94

# 52265 $148.44 $141.02 $162.1752270 $460.33 $437.31 $502.91

# 52270 $168.90 $160.46 $184.5352275 $642.07 $609.97 $701.47

# 52275 $232.52 $220.89 $254.0252276 $247.79 $235.40 $270.7152277 $305.39 $290.12 $333.6452281 $325.96 $309.66 $356.11

# 52281 $142.89 $135.75 $156.1152282 $315.03 $299.28 $344.1752283 $269.90 $256.41 $294.87

# 52283 $186.78 $177.44 $204.0652285 $269.77 $256.28 $294.72

# 52285 $180.93 $171.88 $197.6652290 $228.06 $216.66 $249.1652300 $264.12 $250.91 $288.5552301 $271.25 $257.69 $296.3452305 $261.76 $248.67 $285.9752310 $255.00 $242.25 $278.59

# 52310 $140.92 $133.87 $153.9552315 $464.64 $441.41 $507.62

# 52315 $257.34 $244.47 $281.1452317 $1,119.17 $1,063.21 $1,222.69

# 52317 $327.99 $311.59 $358.3352318 $447.78 $425.39 $489.2052320 $231.17 $219.61 $252.55

52325 $301.99 $286.89 $329.9252327 $1,141.99 $1,084.89 $1,247.62

# 52327 $254.90 $242.16 $278.4852330 $1,335.24 $1,268.48 $1,458.75

# 52330 $247.92 $235.52 $270.8552332 $353.35 $335.68 $386.03

# 52332 $143.69 $136.51 $156.9952334 $239.75 $227.76 $261.9252341 $304.89 $289.65 $333.1052342 $327.99 $311.59 $358.3352343 $361.57 $343.49 $395.0152344 $388.37 $368.95 $424.2952345 $412.48 $391.86 $450.6452346 $461.84 $438.75 $504.5652351 $292.44 $277.82 $319.4952352 $343.77 $326.58 $375.5752353 $396.03 $376.23 $432.6652354 $366.03 $347.73 $399.8952355 $436.92 $415.07 $477.3352400 $506.32 $481.00 $553.1552402 $254.90 $242.16 $278.4852450 $417.65 $396.77 $456.2952500 $492.36 $467.74 $537.9052510 $391.91 $372.31 $428.1652601 $746.38 $709.06 $815.4252606 $457.26 $434.40 $499.5652612 $472.63 $449.00 $516.3552614 $412.62 $391.99 $450.7952620 $375.63 $356.85 $410.3852630 $399.57 $379.59 $436.5352640 $363.38 $345.21 $396.9952647 $2,624.54 $2,493.31 $2,867.31

# 52647 $578.11 $549.20 $631.5852648 $2,659.72 $2,526.73 $2,905.74

# 52648 $618.33 $587.41 $675.5252700 $390.86 $371.32 $427.0253000 $137.97 $131.07 $150.7353010 $261.85 $248.76 $286.0753020 $89.83 $85.34 $98.1453025 $61.18 $58.12 $66.8453040 $360.51 $342.48 $393.8553060 $168.86 $160.42 $184.48

# 53060 $146.31 $138.99 $159.8453080 $441.81 $419.72 $482.6853085 $632.86 $601.22 $691.4053200 $142.76 $135.62 $155.96

# 53200 $130.98 $124.43 $143.0953210 $706.15 $670.84 $771.4753215 $852.33 $809.71 $931.17

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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53220 $409.20 $388.74 $447.0553230 $549.64 $522.16 $600.4853235 $577.34 $548.47 $630.7453240 $384.90 $365.66 $420.5153250 $358.18 $340.27 $391.3153260 $188.06 $178.66 $205.46

# 53260 $162.15 $154.04 $177.1553265 $208.43 $198.01 $227.71

# 53265 $167.71 $159.32 $183.2253270 $191.16 $181.60 $208.84

# 53270 $169.63 $161.15 $185.3253275 $245.72 $233.43 $268.4453400 $730.83 $694.29 $798.4353405 $800.93 $760.88 $875.0153410 $898.15 $853.24 $981.2353415 $1,024.68 $973.45 $1,119.4753420 $758.80 $720.86 $828.9953425 $868.31 $824.89 $948.6253430 $878.75 $834.81 $960.0353431 $1,061.16 $1,008.10 $1,159.3253440 $784.85 $745.61 $857.4553442 $689.21 $654.75 $752.9653444 $727.81 $691.42 $795.1353445 $805.53 $765.25 $880.0453446 $586.85 $557.51 $641.1453447 $748.34 $710.92 $817.5653448 $1,177.69 $1,118.81 $1,286.6353449 $554.16 $526.45 $605.4253450 $365.57 $347.29 $399.3853460 $414.38 $393.66 $452.7153500 $688.62 $654.19 $752.3253502 $442.21 $420.10 $483.1253505 $439.87 $417.88 $480.5653510 $581.58 $552.50 $635.3853515 $731.57 $694.99 $799.2453520 $504.30 $479.09 $550.9553600 $83.01 $78.86 $90.69

# 53600 $60.13 $57.12 $65.6953601 $79.43 $75.46 $86.78

# 53601 $49.48 $47.01 $54.0653605 $61.39 $58.32 $67.0753620 $123.61 $117.43 $135.04

# 53620 $81.21 $77.15 $88.7253621 $116.83 $110.99 $127.64

# 53621 $67.36 $63.99 $73.5953660 $70.01 $66.51 $76.49

# 53660 $37.70 $35.82 $41.1953661 $70.05 $66.55 $76.53

# 53661 $37.41 $35.54 $40.87

53665 $36.52 $34.69 $39.8953850 $3,151.49 $2,993.92 $3,443.01

# 53850 $512.76 $487.12 $560.1953852 $3,019.20 $2,868.24 $3,298.48

# 53852 $555.13 $527.37 $606.4853853 $1,843.00 $1,750.85 $2,013.48

# 53853 $310.44 $294.92 $339.1654000 $152.97 $145.32 $167.12

# 54000 $92.73 $88.09 $101.3054001 $186.43 $177.11 $203.68

# 54001 $122.82 $116.68 $134.1854015 $285.74 $271.45 $312.1754050 $105.06 $99.81 $114.78

# 54050 $83.18 $79.02 $90.8754055 $101.27 $96.21 $110.64

# 54055 $75.69 $71.91 $82.7054056 $107.42 $102.05 $117.36

# 54056 $86.22 $81.91 $94.2054057 $123.56 $117.38 $134.99

# 54057 $78.13 $74.22 $85.3554060 $174.98 $166.23 $191.16

# 54060 $111.38 $105.81 $121.6854065 $181.56 $172.48 $198.35

# 54065 $135.45 $128.68 $147.9854100 $167.08 $158.73 $182.54

# 54100 $100.45 $95.43 $109.7454105 $270.11 $256.60 $295.09

# 54105 $197.76 $187.87 $216.0554110 $567.62 $539.24 $620.1354111 $733.70 $697.02 $801.5754112 $862.51 $819.38 $942.2954115 $406.50 $386.18 $444.11

# 54115 $376.55 $357.72 $411.3854120 $569.70 $541.22 $622.4054125 $740.65 $703.62 $809.1654130 $1,092.48 $1,037.86 $1,193.5454135 $1,395.17 $1,325.41 $1,524.2254150 $120.62 $114.59 $131.78

# 54150 $106.82 $101.48 $116.7054160 $227.23 $215.87 $248.25

# 54160 $131.65 $125.07 $143.8354161 $178.07 $169.17 $194.5554162 $269.52 $256.04 $294.45

# 54162 $173.95 $165.25 $190.0454163 $193.47 $183.80 $211.3754164 $169.02 $160.57 $184.6654200 $101.69 $96.61 $111.10

# 54200 $75.10 $71.35 $82.0554205 $490.25 $465.74 $535.60

54220 $213.48 $202.81 $233.23# 54220 $123.96 $117.76 $135.42

54230 $87.89 $83.50 $96.03# 54230 $72.41 $68.79 $79.11

54231 $125.17 $118.91 $136.75# 54231 $106.66 $101.33 $116.53

54235 $79.23 $75.27 $86.56# 54235 $65.43 $62.16 $71.48

54240 26 $63.53 $60.35 $69.4054240 $89.43 $84.96 $97.7054240 TC $25.89 $24.60 $28.2954250 $115.45 $109.68 $126.1354250 TC $8.74 $8.30 $9.5554250 26 $106.71 $101.37 $116.5854300 $601.02 $570.97 $656.6254304 $704.50 $669.28 $769.6754308 $668.31 $634.89 $730.1254312 $780.36 $741.34 $852.5454316 $936.89 $890.05 $1,023.5654318 $663.30 $630.14 $724.6654322 $733.07 $696.42 $800.8854324 $915.48 $869.71 $1,000.1754326 $890.23 $845.72 $972.5854328 $869.28 $825.82 $949.6954332 $943.17 $896.01 $1,030.4154336 $1,165.13 $1,106.87 $1,272.9054340 $529.41 $502.94 $578.3854344 $906.76 $861.42 $990.6354348 $924.10 $877.90 $1,009.5954352 $1,358.35 $1,290.43 $1,483.9954360 $675.34 $641.57 $737.8154380 $723.65 $687.47 $790.5954385 $865.89 $822.60 $945.9954390 $1,120.95 $1,064.90 $1,224.6454400 $490.19 $465.68 $535.5354401 $588.17 $558.76 $642.5754405 $741.16 $704.10 $809.7254406 $666.00 $632.70 $727.6154408 $713.09 $677.44 $779.0654410 $845.68 $803.40 $923.9154411 $923.04 $876.89 $1,008.4254415 $474.76 $451.02 $518.6754416 $633.35 $601.68 $691.9354417 $810.69 $770.16 $885.6854420 $649.97 $617.47 $710.0954430 $584.66 $555.43 $638.7454435 $376.13 $357.32 $410.9254450 $72.24 $68.63 $78.92

# 54450 $56.09 $53.29 $61.28

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

54500 $68.92 $65.47 $75.2954505 $195.90 $186.11 $214.0354512 $489.34 $464.87 $534.6054520 $297.52 $282.64 $325.0454522 $547.32 $519.95 $597.9454530 $498.06 $473.16 $544.1354535 $681.25 $647.19 $744.2754550 $444.45 $422.23 $485.5654560 $621.58 $590.50 $679.0854600 $407.22 $386.86 $444.8954620 $277.36 $263.49 $303.0154640 $419.43 $398.46 $458.2354650 $657.86 $624.97 $718.7254660 $319.89 $303.90 $349.4954670 $369.89 $351.40 $404.1154680 $733.88 $697.19 $801.7754690 $606.30 $575.99 $662.3954692 $710.27 $674.76 $775.9754700 $195.43 $185.66 $213.5154800 $118.55 $112.62 $129.5154830 $329.37 $312.90 $359.8454840 $292.72 $278.08 $319.7954860 $373.65 $354.97 $408.2254861 $509.52 $484.04 $556.6554865 $317.34 $301.47 $346.6954900 $699.84 $664.85 $764.5854901 $951.04 $903.49 $1,039.0155000 $120.20 $114.19 $131.32

# 55000 $76.79 $72.95 $83.8955040 $304.82 $289.58 $333.0255041 $455.26 $432.50 $497.3855060 $336.93 $320.08 $368.0955100 $209.69 $199.21 $229.09

# 55100 $144.74 $137.50 $158.1355110 $343.68 $326.50 $375.4855120 $315.11 $299.35 $344.2555150 $434.90 $413.16 $475.1355175 $321.76 $305.67 $351.5255180 $623.97 $592.77 $681.6955200 $544.43 $517.21 $594.79

# 55200 $253.00 $240.35 $276.4055250 $476.02 $452.22 $520.05

# 55250 $202.75 $192.61 $221.5055300 $174.49 $165.77 $190.6455400 $461.10 $438.05 $503.7655450 $385.81 $366.52 $421.50

# 55450 $230.33 $218.81 $251.6355500 $340.53 $323.50 $372.0355520 $362.69 $344.56 $396.24

55530 $320.10 $304.10 $349.7255535 $384.33 $365.11 $419.8855540 $442.95 $420.80 $483.9255550 $383.00 $363.85 $418.4355600 $381.88 $362.79 $417.2155605 $465.18 $441.92 $508.2155650 $652.26 $619.65 $712.6055680 $313.99 $298.29 $343.0355700 $228.89 $217.45 $250.07

# 55700 $119.19 $113.23 $130.2155705 $249.26 $236.80 $272.3255720 $430.48 $408.96 $470.3055725 $527.21 $500.85 $575.9855801 $996.26 $946.45 $1,088.4255810 $1,207.93 $1,147.53 $1,319.6655812 $1,485.41 $1,411.14 $1,622.8155815 $1,629.35 $1,547.88 $1,780.0655821 $797.72 $757.83 $871.5055831 $865.38 $822.11 $945.4355840 $1,229.98 $1,168.48 $1,343.7555842 $1,318.81 $1,252.87 $1,440.8055845 $1,512.16 $1,436.55 $1,652.0355860 $805.08 $764.83 $879.5555862 $1,017.77 $966.88 $1,111.9155865 $1,229.76 $1,168.27 $1,343.5155866 $1,604.89 $1,524.65 $1,753.3555870 $152.82 $145.18 $166.96

# 55870 $132.97 $126.32 $145.2755873 $1,058.87 $1,005.93 $1,156.8255875 $698.02 $663.12 $762.5955876 $137.11 $130.25 $149.79

# 55876 $103.12 $97.96 $112.6556405 $98.73 $93.79 $107.86

# 56405 $93.68 $89.00 $102.3556420 $123.46 $117.29 $134.88

# 56420 $86.11 $81.80 $94.0756440 $165.27 $157.01 $180.5656441 $134.75 $128.01 $147.21

# 56441 $123.30 $117.14 $134.7156442 $42.95 $40.80 $46.9256501 $117.24 $111.38 $128.09

# 56501 $100.41 $95.39 $109.7056515 $198.60 $188.67 $216.97

# 56515 $174.70 $165.97 $190.8756605 $76.52 $72.69 $83.59

# 56605 $56.32 $53.50 $61.5356606 $36.38 $34.56 $39.74

# 56606 $27.63 $26.25 $30.1956620 $475.83 $452.04 $519.85

56625 $533.88 $507.19 $583.2756630 $775.03 $736.28 $846.7256631 $993.99 $944.29 $1,085.9356632 $1,135.13 $1,078.37 $1,240.1356633 $1,012.30 $961.69 $1,105.9456634 $1,077.36 $1,023.49 $1,177.0156637 $1,281.97 $1,217.87 $1,400.5556640 $1,280.84 $1,216.80 $1,399.3256700 $166.04 $157.74 $181.4056740 $267.28 $253.92 $292.0156800 $219.71 $208.72 $240.0356805 $1,060.76 $1,007.72 $1,158.8856810 $236.53 $224.70 $258.4156820 $100.24 $95.23 $109.51

# 56820 $78.03 $74.13 $85.2556821 $134.94 $128.19 $147.42

# 56821 $107.01 $101.66 $116.9157000 $170.17 $161.66 $185.9157010 $381.56 $362.48 $416.8557020 $87.12 $82.76 $95.17

# 57020 $75.67 $71.89 $82.6757022 $150.57 $143.04 $164.5057023 $279.19 $265.23 $305.0157061 $102.39 $97.27 $111.86

# 57061 $85.90 $81.61 $93.8557065 $174.87 $166.13 $191.05

# 57065 $155.01 $147.26 $169.3557100 $80.60 $76.57 $88.06

# 57100 $60.74 $57.70 $66.3657105 $123.59 $117.41 $135.02

# 57105 $112.15 $106.54 $122.5257106 $416.19 $395.38 $454.6957107 $1,263.89 $1,200.70 $1,380.8157109 $1,441.55 $1,369.47 $1,574.8957110 $818.06 $777.16 $893.7357111 $1,473.54 $1,399.86 $1,609.8457112 $1,541.20 $1,464.14 $1,683.7657120 $459.71 $436.72 $502.2357130 $163.67 $155.49 $178.81

# 57130 $144.16 $136.95 $157.4957135 $175.71 $166.92 $191.96

# 57135 $156.19 $148.38 $170.6457150 $53.55 $50.87 $58.50

# 57150 $27.63 $26.25 $30.1957155 $390.60 $371.07 $426.7357160 $67.98 $64.58 $74.27

# 57160 $44.42 $42.20 $48.5357170 $76.81 $72.97 $83.92

# 57170 $45.18 $42.92 $49.36

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

57180 $130.91 $124.36 $143.01# 57180 $100.62 $95.59 $109.93

57200 $260.73 $247.69 $284.8457210 $326.52 $310.19 $356.7257220 $283.24 $269.08 $309.4457230 $347.30 $329.94 $379.4357240 $551.90 $524.31 $602.9657250 $543.14 $515.98 $593.3857260 $692.94 $658.29 $757.0357265 $789.72 $750.23 $862.7657267 $250.31 $237.79 $273.4657268 $422.70 $401.57 $461.8157270 $714.99 $679.24 $781.1357280 $867.25 $823.89 $947.4757282 $451.96 $429.36 $493.7657283 $622.08 $590.98 $679.6357284 $744.39 $707.17 $813.2557287 $614.33 $583.61 $671.1557288 $723.85 $687.66 $790.8157289 $677.37 $643.50 $740.0357291 $482.93 $458.78 $527.6057292 $752.60 $714.97 $822.2257295 $439.83 $417.84 $480.5257296 $844.07 $801.87 $922.1557300 $467.30 $443.94 $510.5357305 $787.26 $747.90 $860.0957307 $883.15 $838.99 $964.8457308 $565.00 $536.75 $617.2657310 $414.99 $394.24 $453.3857311 $469.56 $446.08 $512.9957320 $477.88 $453.99 $522.0957330 $687.11 $652.75 $750.6657335 $1,045.15 $992.89 $1,141.8257400 $122.33 $116.21 $133.6457410 $95.79 $91.00 $104.6557415 $139.46 $132.49 $152.3657420 $105.33 $100.06 $115.07

# 57420 $82.78 $78.64 $90.4457421 $143.94 $136.74 $157.25

# 57421 $114.33 $108.61 $124.9057425 $861.69 $818.61 $941.4057452 $99.23 $94.27 $108.41

# 57452 $82.74 $78.60 $90.3957454 $142.09 $134.99 $155.24

# 57454 $125.94 $119.64 $137.5957455 $131.70 $125.12 $143.89

# 57455 $103.44 $98.27 $113.0157456 $124.09 $117.89 $135.57

# 57456 $96.16 $91.35 $105.05

57460 $291.39 $276.82 $318.34# 57460 $152.06 $144.46 $166.13

57461 $322.56 $306.43 $352.39# 57461 $176.50 $167.68 $192.83

57500 $125.70 $119.42 $137.33# 57500 $66.13 $62.82 $72.24

57505 $91.87 $87.28 $100.37# 57505 $80.76 $76.72 $88.23

57510 $122.95 $116.80 $134.32# 57510 $106.46 $101.14 $116.31

57511 $132.46 $125.84 $144.72# 57511 $118.33 $112.41 $129.27

57513 $129.77 $123.28 $141.77# 57513 $119.34 $113.37 $130.38

57520 $282.21 $268.10 $308.32# 57520 $248.22 $235.81 $271.18

57522 $239.86 $227.87 $262.05# 57522 $217.99 $207.09 $238.15

57530 $307.72 $292.33 $336.1857531 $1,549.30 $1,471.84 $1,692.6257540 $703.77 $668.58 $768.8757545 $748.58 $711.15 $817.8257550 $361.82 $343.73 $395.2957555 $540.01 $513.01 $589.9657556 $507.90 $482.51 $554.8957558 $112.73 $107.09 $123.15

# 57558 $101.97 $96.87 $111.4057700 $263.35 $250.18 $287.7157720 $273.23 $259.57 $298.5157800 $54.39 $51.67 $59.42

# 57800 $44.63 $42.40 $48.7658100 $101.04 $95.99 $110.39

# 58100 $81.52 $77.44 $89.0658110 $46.31 $43.99 $50.59

# 58110 $38.91 $36.96 $42.5058120 $214.29 $203.58 $234.12

# 58120 $194.77 $185.03 $212.7858140 $826.96 $785.61 $903.4558145 $488.98 $464.53 $534.2158146 $1,056.18 $1,003.37 $1,153.8858150 $892.33 $847.71 $974.8758152 $1,140.24 $1,083.23 $1,245.7158180 $858.38 $815.46 $937.7858200 $1,190.19 $1,130.68 $1,300.2858210 $1,585.04 $1,505.79 $1,731.6658240 $2,405.95 $2,285.65 $2,628.5058260 $747.64 $710.26 $816.8058262 $837.87 $795.98 $915.3858263 $902.65 $857.52 $986.15

58267 $960.79 $912.75 $1,049.6658270 $804.25 $764.04 $878.6558275 $892.13 $847.52 $974.6558280 $956.96 $909.11 $1,045.4858285 $1,203.40 $1,143.23 $1,314.7158290 $1,056.61 $1,003.78 $1,154.3558291 $1,147.84 $1,090.45 $1,254.0258292 $1,212.96 $1,152.31 $1,325.1658293 $1,259.06 $1,196.11 $1,375.5358294 $1,112.95 $1,057.30 $1,215.9058301 $90.27 $85.76 $98.62

# 58301 $63.35 $60.18 $69.2158321 $71.81 $68.22 $78.45

# 58321 $46.23 $43.92 $50.5158322 $80.89 $76.85 $88.38

# 58322 $54.98 $52.23 $60.0658323 $23.77 $22.58 $25.97

# 58323 $11.99 $11.39 $13.1058340 $130.53 $124.00 $142.60

# 58340 $54.14 $51.43 $59.1458345 $251.25 $238.69 $274.4958346 $404.64 $384.41 $442.0758350 $88.04 $83.64 $96.19

# 58350 $69.87 $66.38 $76.3458353 $1,226.68 $1,165.35 $1,340.15

# 58353 $202.29 $192.18 $221.0158356 $2,155.61 $2,047.83 $2,355.00

# 58356 $327.58 $311.20 $357.8858400 $396.91 $377.06 $433.6258410 $726.93 $690.58 $794.1758520 $703.15 $667.99 $768.1958540 $819.27 $778.31 $895.0658541 $759.11 $721.15 $829.3258542 $840.62 $798.59 $918.3858543 $854.92 $812.17 $934.0058544 $925.88 $879.59 $1,011.5358545 $817.33 $776.46 $892.9358546 $1,037.83 $985.94 $1,133.8358548 $1,618.25 $1,537.34 $1,767.9458550 $803.70 $763.52 $878.0558552 $887.35 $842.98 $969.4358553 $1,042.34 $990.22 $1,138.7558554 $1,191.87 $1,132.28 $1,302.1258555 $205.11 $194.85 $224.08

# 58555 $176.50 $167.68 $192.8358558 $265.26 $252.00 $289.80

# 58558 $249.44 $236.97 $272.5258559 $320.78 $304.74 $350.4558560 $363.31 $345.14 $396.91

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

58561 $515.66 $489.88 $563.3658562 $286.88 $272.54 $313.42

# 58562 $272.74 $259.10 $297.9758563 $1,963.72 $1,865.53 $2,145.36

# 58563 $321.46 $305.39 $351.2058565 $1,817.60 $1,726.72 $1,985.73

# 58565 $407.21 $386.85 $444.8858600 $330.43 $313.91 $361.0058605 $299.51 $284.53 $327.2158611 $73.11 $69.45 $79.8758615 $233.88 $222.19 $255.5258660 $610.69 $580.16 $667.1858661 $592.61 $562.98 $647.4358662 $645.36 $613.09 $705.0558670 $329.42 $312.95 $359.8958671 $329.75 $313.26 $360.2558672 $688.07 $653.67 $751.7258673 $743.10 $705.95 $811.8458700 $685.62 $651.34 $749.0458720 $646.38 $614.06 $706.1758740 $792.59 $752.96 $865.9058750 $828.80 $787.36 $905.4658752 $816.36 $775.54 $891.8758760 $748.96 $711.51 $818.2458770 $781.44 $742.37 $853.7358800 $287.08 $272.73 $313.64

# 58800 $264.20 $250.99 $288.6458805 $356.14 $338.33 $389.0858820 $282.35 $268.23 $308.4658822 $611.73 $581.14 $668.3158823 $821.13 $780.07 $897.08

# 58823 $159.18 $151.22 $173.9058825 $630.82 $599.28 $689.1758900 $363.89 $345.70 $397.5658920 $637.19 $605.33 $696.1358925 $655.09 $622.34 $715.6958940 $444.64 $422.41 $485.7758943 $1,015.42 $964.65 $1,109.3558950 $963.86 $915.67 $1,053.0258951 $1,247.37 $1,185.00 $1,362.7558952 $1,406.11 $1,335.80 $1,536.1758953 $1,751.25 $1,663.69 $1,913.2458954 $1,901.60 $1,806.52 $2,077.5058956 $1,238.53 $1,176.60 $1,353.0958957 $1,310.78 $1,245.24 $1,432.0358958 $1,451.70 $1,379.12 $1,585.9958960 $832.98 $791.33 $910.0358970 $208.18 $197.77 $227.44

# 58970 $182.60 $173.47 $199.49

58976 $229.84 $218.35 $251.10# 58976 $202.24 $192.13 $220.95

59000 $121.31 $115.24 $132.53# 59000 $76.22 $72.41 $83.27

59001 $170.76 $162.22 $186.5559012 $192.91 $183.26 $210.7559015 $143.53 $136.35 $156.80

# 59015 $125.36 $119.09 $136.9559020 $59.64 $56.66 $65.1659020 TC $23.86 $22.67 $26.0759020 26 $35.77 $33.98 $39.0859025 $39.68 $37.70 $43.3659025 TC $10.43 $9.91 $11.4059025 26 $29.26 $27.80 $31.9759030 $107.74 $102.35 $117.7059050 $48.43 $46.01 $52.9159051 $40.15 $38.14 $43.8659070 $354.42 $336.70 $387.21

# 59070 $260.86 $247.82 $284.9959072 $414.90 $394.16 $453.2859074 $335.57 $318.79 $366.61

# 59074 $260.53 $247.50 $284.6359076 $410.87 $390.33 $448.8859100 $762.18 $724.07 $832.6859120 $722.55 $686.42 $789.3859121 $728.55 $692.12 $795.9459130 $795.50 $755.73 $869.0959135 $840.36 $798.34 $918.0959136 $801.86 $761.77 $876.0459140 $322.84 $306.70 $352.7159150 $703.59 $668.41 $768.6759151 $694.51 $659.78 $758.7559160 $214.18 $203.47 $233.99

# 59160 $178.18 $169.27 $194.6659200 $71.27 $67.71 $77.87

# 59200 $42.67 $40.54 $46.6259300 $174.61 $165.88 $190.76

# 59300 $134.23 $127.52 $146.6559320 $143.90 $136.71 $157.2259325 $225.89 $214.60 $246.7959350 $266.18 $252.87 $290.8059400 $1,603.57 $1,523.39 $1,751.9059409 $731.94 $695.34 $799.6459410 $839.05 $797.10 $916.6759412 $97.61 $92.73 $106.6459414 $87.48 $83.11 $95.5859425 $391.54 $371.96 $427.75

# 59425 $310.78 $295.24 $339.5359426 $698.12 $663.21 $762.69

# 59426 $549.03 $521.58 $599.8259430 $129.49 $123.02 $141.47

# 59430 $119.05 $113.10 $130.0759510 $1,812.07 $1,721.47 $1,979.6959514 $865.07 $821.82 $945.0959515 $1,010.05 $959.55 $1,103.4859525 $459.02 $436.07 $501.4859610 $1,679.52 $1,595.54 $1,834.8759612 $820.94 $779.89 $896.8759614 $913.57 $867.89 $998.0759618 $1,900.56 $1,805.53 $2,076.3659620 $946.58 $899.25 $1,034.1459622 $1,095.55 $1,040.77 $1,196.8959812 $271.57 $257.99 $296.69

# 59812 $265.17 $251.91 $289.7059820 $336.95 $320.10 $368.12

# 59820 $310.03 $294.53 $338.7159821 $344.41 $327.19 $376.27

# 59821 $317.15 $301.29 $346.4859830 $399.67 $379.69 $436.6459840 $196.72 $186.88 $214.91

# 59840 $195.03 $185.28 $213.0759841 $345.98 $328.68 $377.98

# 59841 $328.14 $311.73 $358.4959850 $348.25 $330.84 $380.4759851 $366.46 $348.14 $400.3659852 $499.98 $474.98 $546.2359855 $380.31 $361.29 $415.4859856 $458.41 $435.49 $500.8159857 $529.57 $503.09 $578.5559866 $223.29 $212.13 $243.9559870 $414.73 $393.99 $453.0959871 $125.78 $119.49 $137.4160000 $131.26 $124.70 $143.41

# 60000 $122.85 $116.71 $134.2260001 $86.46 $82.14 $94.46

# 60001 $46.07 $43.77 $50.3460100 $101.82 $96.73 $111.24

# 60100 $73.55 $69.87 $80.3560200 $566.54 $538.21 $618.9460210 $605.89 $575.60 $661.9460212 $872.08 $828.48 $952.7560220 $663.36 $630.19 $724.7260225 $797.54 $757.66 $871.3160240 $856.75 $813.91 $936.0060252 $1,148.29 $1,090.88 $1,254.5160254 $1,496.05 $1,421.25 $1,634.4460260 $961.62 $913.54 $1,050.5760270 $1,203.30 $1,143.14 $1,314.61

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

60271 $930.32 $883.80 $1,016.3760280 $376.62 $357.79 $411.4660281 $507.52 $482.14 $554.4660500 $879.19 $835.23 $960.5160502 $1,108.22 $1,052.81 $1,210.7360505 $1,222.80 $1,161.66 $1,335.9160512 $219.70 $208.72 $240.0360520 $922.64 $876.51 $1,007.9960521 $1,055.78 $1,002.99 $1,153.4460522 $1,272.14 $1,208.53 $1,389.8160540 $928.69 $882.26 $1,014.6060545 $1,069.28 $1,015.82 $1,168.1960600 $1,275.63 $1,211.85 $1,393.6360605 $1,581.39 $1,502.32 $1,727.6760650 $1,049.94 $997.44 $1,147.0661000 $92.48 $87.86 $101.0461001 $93.14 $88.48 $101.7561020 $109.99 $104.49 $120.1661026 $116.40 $110.58 $127.1761050 $96.60 $91.77 $105.5461055 $123.40 $117.23 $134.8161070 $71.32 $67.75 $77.9161105 $368.87 $350.43 $402.9961107 $292.94 $278.29 $320.0361108 $732.34 $695.72 $800.0861120 $602.41 $572.29 $658.1361140 $1,058.14 $1,005.23 $1,156.0161150 $1,138.27 $1,081.36 $1,243.5661151 $826.99 $785.64 $903.4961154 $1,048.01 $995.61 $1,144.9561156 $1,065.52 $1,012.24 $1,164.0861210 $340.82 $323.78 $372.3561215 $385.77 $366.48 $421.4561250 $718.46 $682.54 $784.9261253 $805.57 $765.29 $880.0861304 $1,413.90 $1,343.21 $1,544.6961305 $1,690.02 $1,605.52 $1,846.3561312 $1,747.37 $1,660.00 $1,909.0061313 $1,673.27 $1,589.61 $1,828.0561314 $1,538.18 $1,461.27 $1,680.4661315 $1,782.06 $1,692.96 $1,946.9061316 $78.56 $74.63 $85.8261320 $1,646.28 $1,563.97 $1,798.5761321 $1,803.26 $1,713.10 $1,970.0761322 $1,963.21 $1,865.05 $2,144.8161323 $2,009.77 $1,909.28 $2,195.6761330 $1,383.29 $1,314.13 $1,511.2561332 $1,640.89 $1,558.85 $1,792.6861333 $1,632.31 $1,550.69 $1,783.29

61334 $1,069.37 $1,015.90 $1,168.2961340 $1,221.49 $1,160.42 $1,334.4861343 $1,898.39 $1,803.47 $2,073.9961345 $1,745.15 $1,657.89 $1,906.5761440 $1,681.11 $1,597.05 $1,836.6161450 $1,602.12 $1,522.01 $1,750.3161458 $1,732.56 $1,645.93 $1,892.8261460 $1,771.19 $1,682.63 $1,935.0261470 $1,596.45 $1,516.63 $1,744.1261480 $1,631.17 $1,549.61 $1,782.0561490 $1,639.03 $1,557.08 $1,790.6461500 $1,149.37 $1,091.90 $1,255.6961501 $973.96 $925.26 $1,064.0561510 $1,856.25 $1,763.44 $2,027.9661512 $2,218.89 $2,107.95 $2,424.1461514 $1,629.97 $1,548.47 $1,780.7461516 $1,595.26 $1,515.50 $1,742.8361517 $79.19 $75.23 $86.5161518 $2,381.82 $2,262.73 $2,602.1461519 $2,579.31 $2,450.34 $2,817.8961520 $3,298.09 $3,133.19 $3,603.1761521 $2,777.08 $2,638.23 $3,033.9661522 $1,871.59 $1,778.01 $2,044.7161524 $1,783.34 $1,694.17 $1,948.3061526 $3,003.56 $2,853.38 $3,281.3961530 $2,542.42 $2,415.30 $2,777.6061531 $998.90 $948.96 $1,091.3061533 $1,290.15 $1,225.64 $1,409.4961534 $1,378.99 $1,310.04 $1,506.5561535 $808.80 $768.36 $883.6161536 $2,245.71 $2,133.42 $2,453.4361537 $1,992.27 $1,892.66 $2,176.5661538 $2,119.84 $2,013.85 $2,315.9361539 $2,022.15 $1,921.04 $2,209.2061540 $1,915.38 $1,819.61 $2,092.5561541 $1,816.77 $1,725.93 $1,984.8261542 $1,981.99 $1,882.89 $2,165.3261543 $1,867.69 $1,774.31 $2,040.4661544 $1,600.16 $1,520.15 $1,748.1761545 $2,732.57 $2,595.94 $2,985.3361546 $1,974.74 $1,876.00 $2,157.4061548 $1,327.57 $1,261.19 $1,450.3761550 $781.53 $742.45 $853.8261552 $1,011.94 $961.34 $1,105.5461556 $1,369.04 $1,300.59 $1,495.6861557 $1,443.54 $1,371.36 $1,577.0661558 $1,370.25 $1,301.74 $1,497.0061559 $2,087.16 $1,982.80 $2,280.2261563 $1,645.96 $1,563.66 $1,798.21

61564 $2,072.17 $1,968.56 $2,263.8461566 $1,924.07 $1,827.87 $2,102.0561567 $2,139.31 $2,032.34 $2,337.1961570 $1,567.56 $1,489.18 $1,712.5661571 $1,702.42 $1,617.30 $1,859.9061575 $2,049.30 $1,946.84 $2,238.8761576 $3,162.09 $3,003.99 $3,454.5961580 $2,105.52 $2,000.24 $2,300.2861581 $2,259.98 $2,146.98 $2,469.0361582 $2,378.19 $2,259.28 $2,598.1761583 $2,469.95 $2,346.45 $2,698.4261584 $2,390.81 $2,271.27 $2,611.9661585 $2,562.12 $2,434.01 $2,799.1161586 $1,849.09 $1,756.64 $2,020.1461590 $2,695.21 $2,560.45 $2,944.5261591 $2,735.15 $2,598.39 $2,988.1561592 $2,704.53 $2,569.30 $2,954.7061595 $2,005.78 $1,905.49 $2,191.3161596 $2,228.47 $2,117.05 $2,434.6161597 $2,458.03 $2,335.13 $2,685.4061598 $2,196.84 $2,087.00 $2,400.0561600 $1,799.12 $1,709.16 $1,965.5361601 $1,986.26 $1,886.95 $2,169.9961605 $1,904.74 $1,809.50 $2,080.9361606 $2,570.64 $2,442.11 $2,808.4361607 $2,397.71 $2,277.82 $2,619.4961608 $2,804.95 $2,664.70 $3,064.4161609 $576.75 $547.91 $630.1061610 $1,693.82 $1,609.13 $1,850.5061611 $435.91 $414.11 $476.2361612 $1,498.88 $1,423.94 $1,637.5361613 $2,710.81 $2,575.27 $2,961.5661615 $2,110.71 $2,005.17 $2,305.9561616 $2,813.44 $2,672.77 $3,073.6961618 $1,106.98 $1,051.63 $1,209.3761619 $1,284.93 $1,220.68 $1,403.7861623 $503.76 $478.57 $550.3661624 $978.13 $929.22 $1,068.6061626 $787.54 $748.16 $860.3861680 $1,953.34 $1,855.67 $2,134.0261682 $3,735.09 $3,548.34 $4,080.5961684 $2,488.44 $2,364.02 $2,718.6261686 $3,987.42 $3,788.05 $4,356.2661690 $1,851.72 $1,759.13 $2,023.0061692 $3,207.23 $3,046.87 $3,503.9061697 $3,536.79 $3,359.95 $3,863.9461698 $3,723.53 $3,537.35 $4,067.9561700 $3,060.57 $2,907.54 $3,343.6761702 $3,296.42 $3,131.60 $3,601.34

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

61703 $1,129.22 $1,072.76 $1,233.6761705 $2,226.39 $2,115.07 $2,432.3361708 $1,837.87 $1,745.98 $2,007.8861710 $1,665.39 $1,582.12 $1,819.4461711 $2,271.49 $2,157.92 $2,481.6161720 $1,011.36 $960.79 $1,104.9161735 $1,251.74 $1,189.15 $1,367.5261750 $1,191.52 $1,131.94 $1,301.7361751 $1,157.76 $1,099.87 $1,264.8561760 $1,260.43 $1,197.41 $1,377.0261770 $1,299.26 $1,234.30 $1,419.4561790 $701.29 $666.23 $766.1661791 $924.99 $878.74 $1,010.5561793 $1,092.81 $1,038.17 $1,193.9061795 $226.47 $215.15 $247.4261850 $800.46 $760.44 $874.5161860 $1,320.51 $1,254.48 $1,442.6561863 $1,285.31 $1,221.04 $1,404.2061864 $406.21 $385.90 $443.7961867 $1,899.06 $1,804.11 $2,074.7361868 $577.08 $548.23 $630.4661870 $1,001.44 $951.37 $1,094.0861875 $917.00 $871.15 $1,001.8261880 $451.44 $428.87 $493.2061885 $501.16 $476.10 $547.5261886 $631.86 $600.27 $690.3161888 $344.89 $327.65 $376.8062000 $707.03 $671.68 $772.4362005 $1,029.58 $978.10 $1,124.8262010 $1,294.64 $1,229.91 $1,414.4062100 $1,383.18 $1,314.02 $1,511.1262115 $1,370.93 $1,302.38 $1,497.7462116 $1,502.95 $1,427.80 $1,641.9762117 $1,627.97 $1,546.57 $1,778.5662120 $1,531.89 $1,455.30 $1,673.6062121 $1,430.02 $1,358.52 $1,562.3062140 $891.75 $847.16 $974.2362141 $977.19 $928.33 $1,067.5862142 $733.17 $696.51 $800.9962143 $869.05 $825.60 $949.4462145 $1,193.58 $1,133.90 $1,303.9962146 $1,026.96 $975.61 $1,121.9562147 $1,220.74 $1,159.70 $1,333.6662148 $112.49 $106.87 $122.9062160 $176.46 $167.64 $192.7962161 $1,300.93 $1,235.88 $1,421.2662162 $1,599.27 $1,519.31 $1,747.2162163 $1,032.95 $981.30 $1,128.5062164 $1,682.06 $1,597.96 $1,837.65

62165 $1,323.70 $1,257.52 $1,446.1562180 $1,343.48 $1,276.31 $1,467.7662190 $748.93 $711.48 $818.2062192 $816.29 $775.48 $891.8062194 $317.22 $301.36 $346.5662200 $1,173.99 $1,115.29 $1,282.5862201 $992.06 $942.46 $1,083.8362220 $861.78 $818.69 $941.4962223 $866.51 $823.18 $946.6662225 $404.55 $384.32 $441.9762230 $702.79 $667.65 $767.8062252 $84.56 $80.33 $92.3862252 26 $43.51 $41.33 $47.5362252 TC $41.05 $39.00 $44.8562256 $474.61 $450.88 $518.5162258 $953.37 $905.70 $1,041.5662263 $628.77 $597.33 $686.93

# 62263 $337.00 $320.15 $368.1762264 $402.14 $382.03 $439.33

# 62264 $206.28 $195.97 $225.3762268 $520.68 $494.65 $568.85

# 62268 $243.05 $230.90 $265.5462269 $609.64 $579.16 $666.03

# 62269 $246.52 $234.19 $269.3262270 $144.18 $136.97 $157.52

# 62270 $67.79 $64.40 $74.0662272 $168.63 $160.20 $184.23

# 62272 $74.74 $71.00 $81.6562273 $159.93 $151.93 $174.72

# 62273 $100.36 $95.34 $109.6462280 $310.15 $294.64 $338.84

# 62280 $134.15 $127.44 $146.5662281 $270.56 $257.03 $295.58

# 62281 $126.86 $120.52 $138.6062282 $329.24 $312.78 $359.70

# 62282 $117.56 $111.68 $128.4362284 $212.49 $201.87 $232.15

# 62284 $79.56 $75.58 $86.9262287 $496.47 $471.65 $542.4062290 $326.38 $310.06 $356.57

# 62290 $154.08 $146.38 $168.3462291 $292.04 $277.44 $319.06

# 62291 $147.67 $140.29 $161.3362292 $478.52 $454.59 $522.7862294 $664.58 $631.35 $726.0562310 $215.58 $204.80 $235.52

# 62310 $90.39 $85.87 $98.7562311 $202.07 $191.97 $220.77

# 62311 $75.20 $71.44 $82.16

62318 $244.65 $232.42 $267.28# 62318 $93.88 $89.19 $102.57

62319 $217.09 $206.24 $237.18# 62319 $86.86 $82.52 $94.90

62350 $442.63 $420.50 $483.5862351 $713.74 $678.05 $779.7662355 $358.83 $340.89 $392.0262360 $233.36 $221.69 $254.9462361 $384.00 $364.80 $419.5262362 $482.01 $457.91 $526.6062365 $375.49 $356.72 $410.2362367 $36.14 $34.33 $39.48

# 62367 $20.66 $19.63 $22.5762368 $49.94 $47.44 $54.56

# 62368 $33.11 $31.45 $36.1763001 $1,047.03 $994.68 $1,143.8863003 $1,057.98 $1,005.08 $1,155.8463005 $1,001.05 $951.00 $1,093.6563011 $937.55 $890.67 $1,024.2763012 $1,025.59 $974.31 $1,120.4663015 $1,266.21 $1,202.90 $1,383.3463016 $1,298.78 $1,233.84 $1,418.9263017 $1,057.91 $1,005.01 $1,155.7663020 $1,000.43 $950.41 $1,092.9763030 $830.59 $789.06 $907.4263035 $184.08 $174.88 $201.1163040 $1,228.57 $1,167.14 $1,342.2163042 $1,153.39 $1,095.72 $1,260.0863045 $1,090.55 $1,036.02 $1,191.4263046 $1,043.25 $991.09 $1,139.7563047 $956.33 $908.51 $1,044.7963048 $195.42 $185.65 $213.5063050 $1,275.45 $1,211.68 $1,393.4363051 $1,460.11 $1,387.10 $1,595.1763055 $1,411.69 $1,341.11 $1,542.2863056 $1,313.53 $1,247.85 $1,435.0363057 $302.69 $287.56 $330.6963064 $1,558.09 $1,480.19 $1,702.2263066 $186.55 $177.22 $203.8063075 $1,217.46 $1,156.59 $1,330.0863076 $234.53 $222.80 $256.2263077 $1,326.08 $1,259.78 $1,448.7563078 $185.63 $176.35 $202.8063081 $1,548.25 $1,470.84 $1,691.4763082 $252.91 $240.26 $276.3063085 $1,657.34 $1,574.47 $1,810.6463086 $178.59 $169.66 $195.1163087 $2,115.57 $2,009.79 $2,311.2663088 $243.42 $231.25 $265.94

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

63090 $1,714.05 $1,628.35 $1,872.6063091 $165.91 $157.61 $181.2563101 $1,979.36 $1,880.39 $2,162.4563102 $1,977.00 $1,878.15 $2,159.8763103 $265.90 $252.61 $290.5063170 $1,322.26 $1,256.15 $1,444.5763172 $1,184.57 $1,125.34 $1,294.1463173 $1,451.52 $1,378.94 $1,585.7863180 $1,196.99 $1,137.14 $1,307.7163182 $1,287.78 $1,223.39 $1,406.9063185 $940.94 $893.89 $1,027.9763190 $1,089.63 $1,035.15 $1,190.4263191 $1,208.62 $1,148.19 $1,320.4263194 $1,228.43 $1,167.01 $1,342.0663195 $1,279.46 $1,215.49 $1,397.8163196 $1,505.96 $1,430.66 $1,645.2663197 $1,418.08 $1,347.18 $1,549.2663198 $1,517.31 $1,441.44 $1,657.6663199 $1,571.94 $1,493.34 $1,717.3463200 $1,277.57 $1,213.69 $1,395.7463250 $2,475.15 $2,351.39 $2,704.1063251 $2,616.93 $2,486.08 $2,858.9963252 $2,614.84 $2,484.10 $2,856.7263265 $1,423.14 $1,351.98 $1,554.7863266 $1,467.77 $1,394.38 $1,603.5463267 $1,179.62 $1,120.64 $1,288.7463268 $1,155.07 $1,097.32 $1,261.9263270 $1,764.25 $1,676.04 $1,927.4563271 $1,769.70 $1,681.22 $1,933.4063272 $1,632.48 $1,550.86 $1,783.4963273 $1,569.44 $1,490.97 $1,714.6263275 $1,533.44 $1,456.77 $1,675.2963276 $1,528.42 $1,452.00 $1,669.8063277 $1,345.77 $1,278.48 $1,470.2563278 $1,316.97 $1,251.12 $1,438.7963280 $1,818.73 $1,727.79 $1,986.9663281 $1,799.78 $1,709.79 $1,966.2663282 $1,696.27 $1,611.46 $1,853.1863283 $1,606.98 $1,526.63 $1,755.6263285 $2,264.73 $2,151.49 $2,474.2163286 $2,247.93 $2,135.53 $2,455.8663287 $2,356.86 $2,239.02 $2,574.8763290 $2,379.00 $2,260.05 $2,599.0663295 $278.51 $264.58 $304.2763300 $1,585.12 $1,505.86 $1,731.7463301 $1,771.68 $1,683.10 $1,935.5763302 $1,767.33 $1,678.96 $1,930.8063303 $1,846.51 $1,754.18 $2,017.3163304 $1,944.30 $1,847.09 $2,124.15

63305 $2,025.99 $1,924.69 $2,213.3963306 $2,067.32 $1,963.95 $2,258.5463307 $1,910.44 $1,814.92 $2,087.1663308 $303.63 $288.45 $331.7263600 $737.01 $700.16 $805.1863610 $1,949.55 $1,852.07 $2,129.88

# 63610 $395.80 $376.01 $432.4163615 $966.78 $918.44 $1,056.2163650 $380.42 $361.40 $415.6163655 $711.58 $676.00 $777.4063660 $379.35 $360.38 $414.4463685 $438.95 $417.00 $479.5563688 $357.54 $339.66 $390.6163700 $1,051.43 $998.86 $1,148.6963702 $1,165.31 $1,107.04 $1,273.1063704 $1,343.09 $1,275.94 $1,467.3363706 $1,536.82 $1,459.98 $1,678.9863707 $772.25 $733.64 $843.6963709 $946.42 $899.10 $1,033.9763710 $940.63 $893.60 $1,027.6463740 $779.44 $740.47 $851.5463741 $523.57 $497.39 $572.0063744 $549.49 $522.02 $600.3263746 $433.40 $411.73 $473.4964400 $99.80 $94.81 $109.03

# 64400 $55.04 $52.29 $60.1364402 $98.28 $93.37 $107.38

# 64402 $64.97 $61.72 $70.9864405 $94.54 $89.81 $103.28

# 64405 $63.58 $60.40 $69.4664408 $103.63 $98.45 $113.22

# 64408 $79.06 $75.11 $86.3864410 $130.30 $123.79 $142.36

# 64410 $68.04 $64.64 $74.3464412 $126.97 $120.62 $138.71

# 64412 $58.32 $55.40 $63.7164413 $107.63 $102.25 $117.59

# 64413 $66.91 $63.56 $73.0964415 $136.53 $129.70 $149.16

# 64415 $67.88 $64.49 $74.1664416 $166.37 $158.05 $181.7664417 $142.12 $135.01 $155.26

# 64417 $68.42 $65.00 $74.7564418 $129.21 $122.75 $141.16

# 64418 $62.91 $59.76 $68.7264420 $160.62 $152.59 $175.48

# 64420 $57.31 $54.44 $62.6164421 $243.63 $231.45 $266.17

# 64421 $78.39 $74.47 $85.64

64425 $116.67 $110.84 $127.47# 64425 $82.01 $77.91 $89.60

64430 $136.44 $129.62 $149.06# 64430 $73.51 $69.83 $80.30

64435 $134.70 $127.97 $147.17# 64435 $76.81 $72.97 $83.92

64445 $135.18 $128.42 $147.68# 64445 $70.90 $67.36 $77.46

64446 $160.12 $152.11 $174.9364447 $66.95 $63.60 $73.1464448 $145.02 $137.77 $158.4464449 $143.55 $136.37 $156.8364450 $89.60 $85.12 $97.89

# 64450 $64.03 $60.83 $69.9564470 $280.95 $266.90 $306.94

# 64470 $90.47 $85.95 $98.8464472 $115.62 $109.84 $126.32

# 64472 $58.07 $55.17 $63.4564475 $255.74 $242.95 $279.39

# 64475 $72.33 $68.71 $79.0264476 $98.28 $93.37 $107.38

# 64476 $43.76 $41.57 $47.8164479 $299.47 $284.50 $327.18

# 64479 $108.32 $102.90 $118.3464480 $140.14 $133.13 $153.10

# 64480 $71.16 $67.60 $77.7464483 $299.33 $284.36 $327.01

# 64483 $95.73 $90.94 $104.5864484 $144.39 $137.17 $157.75

# 64484 $60.26 $57.25 $65.8464505 $90.29 $85.78 $98.65

# 64505 $72.45 $68.83 $79.1564508 $140.22 $133.21 $153.19

# 64508 $63.49 $60.32 $69.3764510 $147.00 $139.65 $160.60

# 64510 $60.51 $57.48 $66.1064517 $161.16 $153.10 $176.07

# 64517 $105.96 $100.66 $115.7664520 $199.96 $189.96 $218.45

# 64520 $66.70 $63.37 $72.8864530 $191.09 $181.54 $208.77

# 64530 $78.35 $74.43 $85.5964550 $15.15 $14.39 $16.55

# 64550 $8.08 $7.68 $8.8364553 $178.13 $169.22 $194.60

# 64553 $143.81 $136.62 $157.1164555 $184.02 $174.82 $201.04

# 64555 $125.80 $119.51 $137.4464560 $175.60 $166.82 $191.84

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 64560 $132.19 $125.58 $144.4264561 $1,183.83 $1,124.64 $1,293.34

# 64561 $360.68 $342.65 $394.0564565 $168.62 $160.19 $184.22

# 64565 $107.71 $102.32 $117.6764573 $509.85 $484.36 $557.0164575 $253.08 $240.43 $276.4964577 $299.40 $284.43 $327.0964580 $265.39 $252.12 $289.9464581 $710.28 $674.77 $775.9964585 $410.70 $390.17 $448.70

# 64585 $150.23 $142.72 $164.1364590 $322.84 $306.70 $352.71

# 64590 $167.36 $158.99 $182.8464595 $382.51 $363.38 $417.89

# 64595 $132.80 $126.16 $145.0864600 $409.19 $388.73 $447.04

# 64600 $184.39 $175.17 $201.4564605 $521.95 $495.85 $570.23

# 64605 $292.77 $278.13 $319.8564610 $600.01 $570.01 $655.51

# 64610 $420.64 $399.61 $459.5564612 $147.52 $140.14 $161.16

# 64612 $116.22 $110.41 $126.9764613 $156.60 $148.77 $171.09

# 64613 $111.51 $105.93 $121.8264614 $173.27 $164.61 $189.30

# 64614 $122.46 $116.34 $133.7964620 $260.22 $247.21 $284.29

# 64620 $147.14 $139.78 $160.7564622 $338.60 $321.67 $369.92

# 64622 $154.18 $146.47 $168.4464623 $123.90 $117.71 $135.37

# 64623 $43.13 $40.97 $47.1264626 $372.27 $353.66 $406.71

# 64626 $201.99 $191.89 $220.6764627 $175.69 $166.91 $191.95

# 64627 $50.50 $47.98 $55.1864630 $202.63 $192.50 $221.38

# 64630 $161.91 $153.81 $176.8864640 $230.61 $219.08 $251.94

# 64640 $163.31 $155.14 $178.4164650 $54.48 $51.76 $59.52

# 64650 $34.96 $33.21 $38.1964653 $62.89 $59.75 $68.71

# 64653 $44.05 $41.85 $48.1364680 $298.41 $283.49 $326.01

# 64680 $140.92 $133.87 $153.9564681 $413.13 $392.47 $451.34

# 64681 $201.12 $191.06 $219.7264702 $370.75 $352.21 $405.0464704 $288.34 $273.92 $315.0164708 $403.04 $382.89 $440.3264712 $467.34 $443.97 $510.5764713 $648.62 $616.19 $708.6264714 $542.94 $515.79 $593.1664716 $449.69 $427.21 $491.2964718 $479.60 $455.62 $523.9664719 $341.85 $324.76 $373.4764721 $364.53 $346.30 $398.25

# 64721 $363.86 $345.67 $397.5264722 $278.07 $264.17 $303.8064726 $255.20 $242.44 $278.8164727 $170.20 $161.69 $185.9464732 $321.63 $305.55 $351.3864734 $357.06 $339.21 $390.0964736 $326.32 $310.00 $356.5064738 $401.83 $381.74 $439.0064740 $398.03 $378.13 $434.8564742 $410.20 $389.69 $448.1464744 $364.76 $346.52 $398.5064746 $393.59 $373.91 $430.0064752 $431.87 $410.28 $471.8264755 $762.28 $724.17 $832.8064760 $401.91 $381.81 $439.0864761 $376.32 $357.50 $411.1364763 $459.96 $436.96 $502.5064766 $530.70 $504.17 $579.8064771 $499.35 $474.38 $545.5464772 $479.73 $455.74 $524.1064774 $349.33 $331.86 $381.6464776 $337.83 $320.94 $369.0864778 $169.58 $161.10 $185.2764782 $389.00 $369.55 $424.9864783 $201.81 $191.72 $220.4864784 $622.48 $591.36 $680.0664786 $961.31 $913.24 $1,050.2364787 $232.93 $221.28 $254.4764788 $319.57 $303.59 $349.1364790 $718.13 $682.22 $784.5564792 $912.66 $867.03 $997.0864795 $171.53 $162.95 $187.3964802 $557.29 $529.43 $608.8464804 $840.66 $798.63 $918.4264809 $749.24 $711.78 $818.5564818 $596.77 $566.93 $651.9764820 $652.32 $619.70 $712.6664821 $596.73 $566.89 $651.92

64822 $594.36 $564.64 $649.3464823 $686.20 $651.89 $749.6764831 $631.25 $599.69 $689.6464832 $315.09 $299.34 $344.2464834 $651.55 $618.97 $711.8264835 $709.74 $674.25 $775.3964836 $704.71 $669.47 $769.8964837 $349.99 $332.49 $382.3664840 $770.00 $731.50 $841.2364856 $885.61 $841.33 $967.5364857 $928.14 $881.73 $1,013.9964858 $1,073.75 $1,020.06 $1,173.0764859 $238.79 $226.85 $260.8864861 $1,225.82 $1,164.53 $1,339.2164862 $1,215.75 $1,154.96 $1,328.2064864 $777.33 $738.46 $849.2364865 $1,019.90 $968.91 $1,114.2564866 $1,074.40 $1,020.68 $1,173.7864868 $917.91 $872.01 $1,002.8164870 $913.02 $867.37 $997.4864872 $111.83 $106.24 $122.1864874 $164.71 $156.47 $179.9464876 $180.98 $171.93 $197.7264885 $1,019.70 $968.72 $1,114.0364886 $1,201.82 $1,141.73 $1,312.9964890 $955.64 $907.86 $1,044.0464891 $917.35 $871.48 $1,002.2064892 $914.97 $869.22 $999.6064893 $990.27 $940.76 $1,081.8764895 $1,106.67 $1,051.34 $1,209.0464896 $1,227.86 $1,166.47 $1,341.4464897 $1,100.13 $1,045.12 $1,201.8964898 $1,196.95 $1,137.10 $1,307.6764901 $559.12 $531.16 $610.8364902 $641.61 $609.53 $700.9664905 $850.77 $808.23 $929.4664907 $1,153.59 $1,095.91 $1,260.3064910 $615.37 $584.60 $672.2964911 $748.94 $711.49 $818.2165091 $522.82 $496.68 $571.1865093 $526.42 $500.10 $575.1265101 $597.22 $567.36 $652.4665103 $623.14 $591.98 $680.7865105 $685.38 $651.11 $748.7865110 $996.20 $946.39 $1,088.3565112 $1,181.23 $1,122.17 $1,290.5065114 $1,221.70 $1,160.62 $1,334.7165125 $394.04 $374.34 $430.49

# 65125 $232.51 $220.88 $254.01

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

65130 $590.57 $561.04 $645.2065135 $600.67 $570.64 $656.2465140 $649.95 $617.45 $710.0765150 $481.70 $457.62 $526.2665155 $692.76 $658.12 $756.8465175 $531.91 $505.31 $581.1165205 $46.46 $44.14 $50.76

# 65205 $35.35 $33.58 $38.6265210 $56.72 $53.88 $61.96

# 65210 $43.26 $41.10 $47.2765220 $47.12 $44.76 $51.47

# 65220 $35.34 $33.57 $38.6165222 $62.45 $59.33 $68.23

# 65222 $46.63 $44.30 $50.9565235 $541.24 $514.18 $591.3165260 $758.15 $720.24 $828.2865265 $852.43 $809.81 $931.2865270 $232.79 $221.15 $254.32

# 65270 $114.00 $108.30 $124.5565272 $408.81 $388.37 $446.63

# 65272 $270.50 $256.98 $295.5365273 $298.10 $283.20 $325.6865275 $431.56 $409.98 $471.48

# 65275 $351.47 $333.90 $383.9965280 $523.74 $497.55 $572.1865285 $820.17 $779.16 $896.0365286 $585.53 $556.25 $639.69

# 65286 $383.95 $364.75 $419.4665290 $385.24 $365.98 $420.8865400 $533.14 $506.48 $582.45

# 65400 $463.47 $440.30 $506.3565410 $120.00 $114.00 $131.10

# 65410 $84.33 $80.11 $92.1365420 $434.08 $412.38 $474.24

# 65420 $298.12 $283.21 $325.6965426 $538.11 $511.20 $587.88

# 65426 $374.56 $355.83 $409.2065430 $94.43 $89.71 $103.17

# 65430 $84.67 $80.44 $92.5165435 $65.43 $62.16 $71.48

# 65435 $56.35 $53.53 $61.5665436 $304.36 $289.14 $332.51

# 65436 $290.90 $276.36 $317.8165450 $254.02 $241.32 $277.52

# 65450 $249.98 $237.48 $273.1065600 $309.61 $294.13 $338.25

# 65600 $258.79 $245.85 $282.7365710 $872.37 $828.75 $953.0665730 $967.77 $919.38 $1,057.29

65750 $986.25 $936.94 $1,077.4865755 $979.77 $930.78 $1,070.4065770 $1,126.85 $1,070.51 $1,231.0965772 $357.75 $339.86 $390.84

# 65772 $314.68 $298.95 $343.7965775 $435.15 $413.39 $475.4065780 $708.03 $672.63 $773.5265781 $1,069.84 $1,016.35 $1,168.8065782 $923.61 $877.43 $1,009.0465800 $125.73 $119.44 $137.36

# 65800 $107.22 $101.86 $117.1465805 $137.85 $130.96 $150.60

# 65805 $107.22 $101.86 $117.1465810 $360.80 $342.76 $394.1765815 $528.73 $502.29 $577.63

# 65815 $369.21 $350.75 $403.3665820 $605.59 $575.31 $661.6165850 $677.79 $643.90 $740.4965855 $278.68 $264.75 $304.46

# 65855 $240.65 $228.62 $262.9165860 $257.85 $244.96 $281.70

# 65860 $208.72 $198.28 $228.0265865 $385.31 $366.04 $420.9565870 $467.59 $444.21 $510.8465875 $495.03 $470.28 $540.8265880 $523.06 $496.91 $571.4565900 $772.55 $733.92 $844.0165920 $617.57 $586.69 $674.6965930 $516.28 $490.47 $564.0466020 $157.23 $149.37 $171.78

# 66020 $105.07 $99.82 $114.7966030 $139.77 $132.78 $152.70

# 66030 $87.61 $83.23 $95.7166130 $584.70 $555.47 $638.79

# 66130 $461.19 $438.13 $503.8566150 $676.46 $642.64 $739.0466155 $673.07 $639.42 $735.3366160 $767.34 $728.97 $838.3266165 $660.24 $627.23 $721.3166170 $926.02 $879.72 $1,011.6866172 $1,158.82 $1,100.88 $1,266.0166180 $927.18 $880.82 $1,012.9466185 $580.08 $551.08 $633.7466220 $560.17 $532.16 $611.9866225 $732.25 $695.64 $799.9966250 $620.96 $589.91 $678.40

# 66250 $430.15 $408.64 $469.9466500 $285.16 $270.90 $311.5466505 $310.82 $295.28 $339.57

66600 $631.62 $600.04 $690.0566605 $835.26 $793.50 $912.5366625 $341.80 $324.71 $373.4266630 $443.65 $421.47 $484.6966635 $447.69 $425.31 $489.1166680 $398.96 $379.01 $435.8666682 $479.49 $455.52 $523.8566700 $354.76 $337.02 $387.57

# 66700 $311.35 $295.78 $340.1566710 $350.72 $333.18 $383.16

# 66710 $308.66 $293.23 $337.2166711 $491.04 $466.49 $536.4666720 $366.78 $348.44 $400.71

# 66720 $330.77 $314.23 $361.3666740 $348.03 $330.63 $380.22

# 66740 $312.02 $296.42 $340.8866761 $357.42 $339.55 $390.48

# 66761 $318.04 $302.14 $347.4666762 $373.66 $354.98 $408.23

# 66762 $330.58 $314.05 $361.1666770 $414.48 $393.76 $452.82

# 66770 $374.09 $355.39 $408.7066820 $326.89 $310.55 $357.1366821 $253.28 $240.62 $276.71

# 66821 $238.13 $226.22 $260.1566825 $610.35 $579.83 $666.8066830 $559.60 $531.62 $611.3666840 $547.72 $520.33 $598.3866850 $621.79 $590.70 $679.3166852 $667.15 $633.79 $728.8666920 $595.74 $565.95 $650.8466930 $675.65 $641.87 $738.1566940 $613.71 $583.02 $670.4766982 $854.68 $811.95 $933.7466983 $560.16 $532.15 $611.9766984 $609.86 $579.37 $666.2866985 $593.99 $564.29 $648.9366986 $740.56 $703.53 $809.0666990 $76.09 $72.29 $83.1367005 $368.91 $350.46 $403.0367010 $428.20 $406.79 $467.8167015 $462.78 $439.64 $505.5967025 $581.98 $552.88 $635.81

# 67025 $489.78 $465.29 $535.0867027 $674.46 $640.74 $736.8567028 $177.19 $168.33 $193.58

# 67028 $137.82 $130.93 $150.5767030 $406.15 $385.84 $443.7267031 $305.58 $290.30 $333.85

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

# 67031 $275.63 $261.85 $301.1367036 $766.93 $728.58 $837.8767038 $1,339.19 $1,272.23 $1,463.0667039 $984.10 $934.90 $1,075.1467040 $1,135.26 $1,078.50 $1,240.2867101 $609.51 $579.03 $665.88

# 67101 $524.37 $498.15 $572.8767105 $565.84 $537.55 $618.18

# 67105 $503.24 $478.08 $549.7967107 $958.39 $910.47 $1,047.0467108 $1,279.23 $1,215.27 $1,397.5667110 $692.32 $657.70 $756.36

# 67110 $604.15 $573.94 $660.0367112 $1,050.48 $997.96 $1,147.6567115 $381.62 $362.54 $416.9267120 $526.06 $499.76 $574.72

# 67120 $431.16 $409.60 $471.0467121 $712.30 $676.69 $778.1967141 $408.50 $388.08 $446.29

# 67141 $376.87 $358.03 $411.7367145 $410.48 $389.96 $448.45

# 67145 $385.24 $365.98 $420.8867208 $470.75 $447.21 $514.29

# 67208 $451.57 $428.99 $493.3467210 $551.46 $523.89 $602.47

# 67210 $529.93 $503.43 $578.9467218 $1,121.18 $1,065.12 $1,224.8967220 $849.52 $807.04 $928.10

# 67220 $804.76 $764.52 $879.2067221 $259.10 $246.15 $283.07

# 67221 $182.04 $172.94 $198.8867225 $25.00 $23.75 $27.31

# 67225 $23.31 $22.14 $25.4667227 $481.39 $457.32 $525.92

# 67227 $447.40 $425.03 $488.7867228 $863.68 $820.50 $943.58

# 67228 $770.47 $731.95 $841.7467250 $636.68 $604.85 $695.5867255 $678.02 $644.12 $740.7467311 $471.41 $447.84 $515.0267312 $562.74 $534.60 $614.7967314 $525.37 $499.10 $573.9767316 $632.43 $600.81 $690.9367318 $550.15 $522.64 $601.0467320 $258.15 $245.24 $282.0367331 $244.31 $232.09 $266.9067332 $266.15 $252.84 $290.7767334 $239.97 $227.97 $262.1767335 $125.57 $119.29 $137.18

67340 $287.69 $273.31 $314.3167343 $512.45 $486.83 $559.8567345 $191.70 $182.12 $209.44

# 67345 $173.19 $164.53 $189.2167346 $164.36 $156.14 $179.5667400 $759.21 $721.25 $829.4467405 $639.62 $607.64 $698.7967412 $713.43 $677.76 $779.4267413 $708.04 $672.64 $773.5467414 $1,033.51 $981.83 $1,129.1067415 $87.45 $83.08 $95.5467420 $1,338.47 $1,271.55 $1,462.2867430 $1,022.80 $971.66 $1,117.4167440 $982.53 $933.40 $1,073.4167445 $1,134.18 $1,077.47 $1,239.0967450 $1,015.58 $964.80 $1,109.5267500 $73.15 $69.49 $79.91

# 67500 $62.38 $59.26 $68.1567505 $66.75 $63.41 $72.92

# 67505 $56.31 $53.49 $61.5167515 $70.63 $67.10 $77.17

# 67515 $63.90 $60.71 $69.8267550 $787.15 $747.79 $859.9667560 $799.19 $759.23 $873.1167570 $945.84 $898.55 $1,033.3367700 $238.08 $226.18 $260.11

# 67700 $91.35 $86.78 $99.8067710 $204.55 $194.32 $223.47

# 67710 $77.34 $73.47 $84.4967715 $212.71 $202.07 $232.38

# 67715 $87.19 $82.83 $95.2567800 $102.88 $97.74 $112.40

# 67800 $84.03 $79.83 $91.8067801 $131.70 $125.12 $143.89

# 67801 $108.82 $103.38 $118.8967805 $162.63 $154.50 $177.68

# 67805 $134.02 $127.32 $146.4267808 $285.22 $270.96 $311.6067810 $169.85 $161.36 $185.56

# 67810 $75.63 $71.85 $82.6367820 $44.77 $42.53 $48.91

# 67820 $43.76 $41.57 $47.8167825 $105.95 $100.65 $115.75

# 67825 $96.86 $92.02 $105.8267830 $235.40 $223.63 $257.17

# 67830 $110.88 $105.34 $121.1467835 $352.83 $335.19 $385.4767840 $245.08 $232.83 $267.75

# 67840 $127.96 $121.56 $139.79

67850 $173.77 $165.08 $189.84# 67850 $110.17 $104.66 $120.36

67875 $152.18 $144.57 $166.26# 67875 $79.15 $75.19 $86.47

67880 $372.72 $354.08 $407.19# 67880 $285.89 $271.60 $312.34

67882 $456.46 $433.64 $498.69# 67882 $368.96 $350.51 $403.09

67900 $533.26 $506.60 $582.59# 67900 $413.46 $392.79 $451.71

67901 $487.05 $462.70 $532.11# 67901 $455.42 $432.65 $497.55

67902 $543.94 $516.74 $594.2567903 $533.52 $506.84 $582.87

# 67903 $411.69 $391.11 $449.7867904 $594.79 $565.05 $649.81

# 67904 $459.84 $436.85 $502.3867906 $414.99 $394.24 $453.3867908 $402.03 $381.93 $439.22

# 67908 $357.28 $339.42 $390.3367909 $453.19 $430.53 $495.11

# 67909 $358.29 $340.38 $391.4467911 $427.21 $405.85 $466.7367912 $810.15 $769.64 $885.09

# 67912 $401.61 $381.53 $438.7667914 $333.78 $317.09 $364.65

# 67914 $233.16 $221.50 $254.7367915 $303.99 $288.79 $332.11

# 67915 $207.41 $197.04 $226.6067916 $450.84 $428.30 $492.55

# 67916 $348.87 $331.43 $381.1467917 $491.22 $466.66 $536.66

# 67917 $385.89 $366.60 $421.5967921 $318.59 $302.66 $348.06

# 67921 $217.97 $207.07 $238.1367922 $297.13 $282.27 $324.61

# 67922 $201.22 $191.16 $219.8367923 $473.52 $449.84 $517.32

# 67923 $375.93 $357.13 $410.7067924 $494.34 $469.62 $540.06

# 67924 $362.76 $344.62 $396.3167930 $311.94 $296.34 $340.79

# 67930 $200.55 $190.52 $219.1067935 $500.68 $475.65 $547.00

# 67935 $369.77 $351.28 $403.9767938 $216.79 $205.95 $236.84

# 67938 $90.26 $85.75 $98.6167950 $487.77 $463.38 $532.89

# 67950 $382.09 $362.99 $417.44

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

67961 $485.25 $460.99 $530.14# 67961 $371.84 $353.25 $406.24

67966 $614.10 $583.40 $670.91# 67966 $504.06 $478.86 $550.69

67971 $592.47 $562.85 $647.2867973 $770.45 $731.93 $841.7267974 $767.29 $728.93 $838.2767975 $558.63 $530.70 $610.3168020 $95.81 $91.02 $104.67

# 68020 $89.08 $84.63 $97.3268040 $53.36 $50.69 $58.29

# 68040 $44.27 $42.06 $48.3768100 $150.50 $142.98 $164.43

# 68100 $79.82 $75.83 $87.2068110 $193.92 $184.22 $211.85

# 68110 $118.53 $112.60 $129.4968115 $272.89 $259.25 $298.14

# 68115 $148.03 $140.63 $161.7268130 $455.80 $433.01 $497.96

# 68130 $329.60 $313.12 $360.0968135 $125.86 $119.57 $137.51

# 68135 $120.81 $114.77 $131.9968200 $34.84 $33.10 $38.07

# 68200 $28.11 $26.70 $30.7168320 $592.56 $562.93 $647.37

# 68320 $414.20 $393.49 $452.5168325 $519.34 $493.37 $567.3868326 $505.43 $480.16 $552.1868328 $573.93 $545.23 $627.0168330 $501.63 $476.55 $548.03

# 68330 $357.93 $340.03 $391.0368335 $506.94 $481.59 $553.8368340 $455.22 $432.46 $497.33

# 68340 $309.16 $293.70 $337.7668360 $437.80 $415.91 $478.30

# 68360 $319.01 $303.06 $348.5268362 $512.54 $486.91 $559.9568371 $339.22 $322.26 $370.6068400 $247.13 $234.77 $269.99

# 68400 $117.57 $111.69 $128.4468420 $278.73 $264.79 $304.51

# 68420 $148.50 $141.08 $162.2468440 $97.53 $92.65 $106.55

# 68440 $76.66 $72.83 $83.7568500 $765.99 $727.69 $836.8468505 $787.57 $748.19 $860.4268510 $394.75 $375.01 $431.26

# 68510 $235.24 $223.48 $257.0068520 $548.89 $521.45 $599.67

68525 $223.46 $212.29 $244.1368530 $385.48 $366.21 $421.14

# 68530 $215.87 $205.08 $235.8468540 $735.27 $698.51 $803.2968550 $909.27 $863.81 $993.3868700 $472.06 $448.46 $515.7368705 $205.79 $195.50 $224.83

# 68705 $133.43 $126.76 $145.7768720 $606.96 $576.61 $663.1068745 $609.63 $579.15 $666.0268750 $624.47 $593.25 $682.2468760 $174.23 $165.52 $190.35

# 68760 $116.35 $110.53 $127.1168761 $122.02 $115.92 $133.31

# 68761 $93.08 $88.43 $101.6968770 $417.80 $396.91 $456.4568801 $98.54 $93.61 $107.65

# 68801 $84.07 $79.87 $91.8568810 $214.98 $204.23 $234.86

# 68810 $184.02 $174.82 $201.0468811 $165.24 $156.98 $180.5368815 $379.12 $360.16 $414.18

# 68815 $208.16 $197.75 $227.4168840 $98.71 $93.77 $107.84

# 68840 $84.58 $80.35 $92.4068850 $56.55 $53.72 $61.78

# 68850 $50.49 $47.97 $55.1769000 $149.60 $142.12 $163.44

# 69000 $99.12 $94.16 $108.2869005 $175.69 $166.91 $191.95

# 69005 $136.99 $130.14 $149.6669020 $188.43 $179.01 $205.86

# 69020 $122.13 $116.02 $133.4269100 $87.56 $83.18 $95.66

# 69100 $42.13 $40.02 $46.0269105 $111.23 $105.67 $121.52

# 69105 $56.04 $53.24 $61.2369110 $362.47 $344.35 $396.00

# 69110 $277.33 $263.46 $302.9869120 $350.65 $333.12 $383.0969140 $734.81 $698.07 $802.7869145 $298.11 $283.20 $325.68

# 69145 $206.91 $196.56 $226.0469150 $928.45 $882.03 $1,014.3369155 $1,469.91 $1,396.41 $1,605.8769200 $105.22 $99.96 $114.95

# 69200 $47.00 $44.65 $51.3569205 $88.35 $83.93 $96.5269210 $43.04 $40.89 $47.02

# 69210 $29.58 $28.10 $32.3269220 $110.52 $104.99 $120.74

# 69220 $54.31 $51.59 $59.3369222 $180.73 $171.69 $197.44

# 69222 $119.14 $113.18 $130.1669300 $440.95 $418.90 $481.74

# 69300 $398.21 $378.30 $435.0569310 $929.61 $883.13 $1,015.6069320 $1,331.65 $1,265.07 $1,454.8369400 $107.15 $101.79 $117.06

# 69400 $52.97 $50.32 $57.8769401 $67.02 $63.67 $73.22

# 69401 $44.47 $42.25 $48.5969405 $214.31 $203.59 $234.13

# 69405 $170.90 $162.36 $186.7169420 $154.86 $147.12 $169.19

# 69420 $101.69 $96.61 $111.1069421 $133.49 $126.82 $145.8469424 $104.50 $99.28 $114.17

# 69424 $53.68 $51.00 $58.6569433 $161.00 $152.95 $175.89

# 69433 $110.86 $105.32 $121.1269436 $146.15 $138.84 $159.6769440 $572.05 $543.45 $624.9769450 $442.97 $420.82 $483.9469501 $628.90 $597.46 $687.0869502 $835.35 $793.58 $912.6269505 $1,039.58 $987.60 $1,135.7469511 $1,066.47 $1,013.15 $1,165.1269530 $1,440.07 $1,368.07 $1,573.2869535 $2,380.99 $2,261.94 $2,601.2369540 $169.87 $161.38 $185.59

# 69540 $109.30 $103.84 $119.4269550 $891.95 $847.35 $974.4569552 $1,386.82 $1,317.48 $1,515.1069554 $2,271.74 $2,158.15 $2,481.8769601 $901.57 $856.49 $984.9669602 $934.13 $887.42 $1,020.5369603 $1,109.08 $1,053.63 $1,211.6769604 $962.69 $914.56 $1,051.7469605 $1,359.93 $1,291.93 $1,485.7269610 $341.24 $324.18 $372.81

# 69610 $265.52 $252.24 $290.0869620 $584.19 $554.98 $638.23

# 69620 $422.32 $401.20 $461.3869631 $736.97 $700.12 $805.1469632 $914.18 $868.47 $998.7469633 $878.42 $834.50 $959.6869635 $1,040.85 $988.81 $1,137.13

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

69636 $1,190.41 $1,130.89 $1,300.5269637 $1,183.93 $1,124.73 $1,293.4469641 $888.77 $844.33 $970.9869642 $1,152.48 $1,094.86 $1,259.0969643 $1,051.39 $998.82 $1,148.6469644 $1,288.45 $1,224.03 $1,407.6369645 $1,258.87 $1,195.93 $1,375.3269646 $1,342.26 $1,275.15 $1,466.4269650 $680.60 $646.57 $743.5669660 $802.49 $762.37 $876.7369661 $1,055.72 $1,002.93 $1,153.3769662 $1,013.15 $962.49 $1,106.8669666 $687.67 $653.29 $751.2869667 $687.71 $653.32 $751.3269670 $809.01 $768.56 $883.8469676 $707.05 $671.70 $772.4669700 $603.18 $573.02 $658.9769711 $738.12 $701.21 $806.3969714 $935.32 $888.55 $1,021.8369715 $1,171.78 $1,113.19 $1,280.1769717 $1,012.49 $961.87 $1,106.1569718 $1,314.20 $1,248.49 $1,435.7669720 $1,010.32 $959.80 $1,103.7769725 $1,664.84 $1,581.60 $1,818.8469740 $1,027.55 $976.17 $1,122.6069745 $1,093.66 $1,038.98 $1,194.8369801 $629.65 $598.17 $687.9069802 $892.44 $847.82 $974.9969805 $917.07 $871.22 $1,001.9069806 $818.82 $777.88 $894.5669820 $750.84 $713.30 $820.3069840 $809.13 $768.67 $883.9769905 $782.33 $743.21 $854.6969910 $890.65 $846.12 $973.0469915 $1,358.36 $1,290.44 $1,484.0169930 $1,118.43 $1,062.51 $1,221.8969950 $1,619.45 $1,538.48 $1,769.2569955 $1,766.52 $1,678.19 $1,929.9269960 $1,706.71 $1,621.37 $1,864.5869970 $1,917.95 $1,822.05 $2,095.3669990 $203.74 $193.55 $222.5870010 $190.90 $181.36 $208.5670010 TC $135.89 $129.10 $148.4770010 26 $55.01 $52.26 $60.1070015 $112.52 $106.89 $122.9270015 TC $56.51 $53.68 $61.7370015 26 $56.01 $53.21 $61.1970030 26 $8.04 $7.64 $8.7970030 $23.85 $22.66 $26.06

70030 TC $15.81 $15.02 $17.2770100 TC $18.50 $17.58 $20.2270100 26 $8.42 $8.00 $9.2070100 $26.92 $25.57 $29.4170110 $34.24 $32.53 $37.4170110 TC $22.87 $21.73 $24.9970110 26 $11.36 $10.79 $12.4170120 $30.62 $29.09 $33.4570120 TC $22.20 $21.09 $24.2570120 26 $8.42 $8.00 $9.2070130 26 $16.12 $15.31 $17.6170130 $46.05 $43.75 $50.3170130 TC $29.94 $28.44 $32.7170134 $42.69 $40.56 $46.6470134 TC $26.57 $25.24 $29.0370134 26 $16.12 $15.31 $17.6170140 $29.65 $28.17 $32.4070140 TC $20.85 $19.81 $22.7870140 26 $8.80 $8.36 $9.6170150 $39.32 $37.35 $42.9570150 TC $27.58 $26.20 $30.1370150 26 $11.74 $11.15 $12.8270160 $26.88 $25.54 $29.3770160 TC $18.84 $17.90 $20.5970160 26 $8.04 $7.64 $8.7970170 26 $13.93 $13.23 $15.2170190 $32.09 $30.49 $35.0670190 TC $22.20 $21.09 $24.2570190 26 $9.89 $9.40 $10.8170200 $40.42 $38.40 $44.1670200 TC $27.58 $26.20 $30.1370200 26 $12.84 $12.20 $14.0370210 $29.23 $27.77 $31.9470210 TC $21.19 $20.13 $23.1570210 26 $8.04 $7.64 $8.7970220 26 $11.36 $10.79 $12.4170220 TC $26.57 $25.24 $29.0370220 $37.93 $36.03 $41.4370240 26 $8.80 $8.36 $9.6170240 TC $15.81 $15.02 $17.2770240 $24.61 $23.38 $26.8970250 $33.56 $31.88 $36.6670250 TC $22.20 $21.09 $24.2570250 26 $11.36 $10.79 $12.4170260 26 $16.12 $15.31 $17.6170260 $46.72 $44.38 $51.0470260 TC $30.61 $29.08 $33.4470300 26 $5.43 $5.16 $5.9370300 $14.51 $13.78 $15.85

70300 TC $9.08 $8.63 $9.9270310 $25.82 $24.53 $28.2170310 TC $17.83 $16.94 $19.4870310 26 $7.99 $7.59 $8.7370320 $39.53 $37.55 $43.1870320 TC $28.93 $27.48 $31.6070320 26 $10.61 $10.08 $11.5970328 $25.91 $24.61 $28.3070328 TC $17.49 $16.62 $19.1170328 26 $8.42 $8.00 $9.2070330 26 $11.36 $10.79 $12.4170330 TC $30.27 $28.76 $33.0770330 $41.64 $39.56 $45.4970332 TC $67.61 $64.23 $73.8670332 $93.24 $88.58 $101.8770332 26 $25.63 $24.35 $28.0070336 $465.14 $441.88 $508.1670336 TC $396.59 $376.76 $433.2770336 26 $68.56 $65.13 $74.9070350 $20.82 $19.78 $22.7570350 TC $12.45 $11.83 $13.6070350 26 $8.37 $7.95 $9.1470355 $27.33 $25.96 $29.8570355 TC $17.82 $16.93 $19.4770355 26 $9.51 $9.03 $10.3870360 $23.51 $22.33 $25.6870360 TC $15.47 $14.70 $16.9170360 26 $8.04 $7.64 $8.7970370 $62.79 $59.65 $68.6070370 TC $48.10 $45.70 $52.5670370 26 $14.69 $13.96 $16.0570371 $106.16 $100.85 $115.9870371 TC $66.93 $63.58 $73.1270371 26 $39.22 $37.26 $42.8570373 26 $20.20 $19.19 $22.0770373 $81.08 $77.03 $88.5870373 TC $60.88 $57.84 $66.5270380 26 $8.04 $7.64 $8.7970380 $32.59 $30.96 $35.6070380 TC $24.55 $23.32 $26.8270390 $83.85 $79.66 $91.6170390 TC $66.26 $62.95 $72.3970390 26 $17.59 $16.71 $19.2270450 $203.71 $193.52 $222.5570450 TC $164.49 $156.27 $179.7170450 26 $39.22 $37.26 $42.8570460 26 $52.44 $49.82 $57.2970460 $254.26 $241.55 $277.7870460 TC $201.83 $191.74 $220.50

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

70470 26 $59.00 $56.05 $64.4670470 $309.60 $294.12 $338.2470470 TC $250.60 $238.07 $273.7870480 $251.13 $238.57 $274.3670480 TC $191.75 $182.16 $209.4870480 26 $59.38 $56.41 $64.8770481 $292.89 $278.25 $319.9970481 TC $229.09 $217.64 $250.2970481 26 $63.80 $60.61 $69.7070482 TC $278.20 $264.29 $303.9370482 26 $66.75 $63.41 $72.9270482 $344.95 $327.70 $376.8670486 TC $178.62 $169.69 $195.1470486 26 $52.82 $50.18 $57.7170486 $231.44 $219.87 $252.8570487 $276.77 $262.93 $302.3770487 TC $216.30 $205.49 $236.3170487 26 $60.48 $57.46 $66.0870488 $335.77 $318.98 $366.8370488 TC $270.12 $256.61 $295.1070488 26 $65.65 $62.37 $71.7370490 $235.31 $223.54 $257.0770490 TC $175.93 $167.13 $192.2070490 26 $59.38 $56.41 $64.8770491 $277.07 $263.22 $302.7070491 TC $213.27 $202.61 $233.0070491 26 $63.80 $60.61 $69.7070492 TC $267.43 $254.06 $292.1770492 26 $66.75 $63.41 $72.9270492 $334.18 $317.47 $365.0970496 $499.82 $474.83 $546.0570496 TC $418.80 $397.86 $457.5470496 26 $81.01 $76.96 $88.5070498 $500.49 $475.47 $546.7970498 TC $419.48 $398.51 $458.2970498 26 $81.01 $76.96 $88.5070540 26 $62.33 $59.21 $68.0970540 $468.40 $444.98 $511.7370540 TC $406.07 $385.77 $443.6470542 26 $74.83 $71.09 $81.7570542 $547.51 $520.13 $598.1570542 TC $472.68 $449.05 $516.4170543 $900.38 $855.36 $983.6670543 TC $800.69 $760.66 $874.7670543 26 $99.70 $94.72 $108.9370544 $481.59 $457.51 $526.1470544 26 $55.72 $52.93 $60.8770544 TC $425.87 $404.58 $465.2770545 26 $55.38 $52.61 $60.50

70545 TC $425.53 $404.25 $464.8970545 $480.92 $456.87 $525.4070546 26 $83.24 $79.08 $90.9470546 TC $773.50 $734.83 $845.0570546 $856.75 $813.91 $936.0070547 $481.25 $457.19 $525.7770547 26 $55.38 $52.61 $60.5070547 TC $425.87 $404.58 $465.2770548 $487.98 $463.58 $533.1270548 TC $432.60 $410.97 $472.6270548 26 $55.38 $52.61 $60.5070549 26 $83.24 $79.08 $90.9470549 $856.41 $813.59 $935.6370549 TC $773.17 $734.51 $844.6970551 26 $68.56 $65.13 $74.9070551 $482.98 $458.83 $527.6570551 TC $414.43 $393.71 $452.7770552 $565.19 $536.93 $617.4770552 TC $482.71 $458.57 $527.3670552 26 $82.49 $78.37 $90.1370553 $919.22 $873.26 $1,004.2570553 TC $810.30 $769.79 $885.2670553 26 $108.92 $103.47 $118.9970554 $556.67 $528.84 $608.1770554 TC $461.13 $438.07 $503.7870554 26 $95.53 $90.75 $104.3670555 26 $27.90 $26.51 $30.4970557 26 $137.25 $130.39 $149.9570558 26 $152.53 $144.90 $166.6470559 26 $152.52 $144.89 $166.6271010 26 $8.42 $8.00 $9.2071010 $23.89 $22.70 $26.1171010 TC $15.47 $14.70 $16.9171015 26 $9.89 $9.40 $10.8171015 $27.72 $26.33 $30.2871015 TC $17.83 $16.94 $19.4871020 $31.46 $29.89 $34.3771020 TC $21.19 $20.13 $23.1571020 26 $10.27 $9.76 $11.2271021 TC $25.22 $23.96 $27.5571021 $37.68 $35.80 $41.1771021 26 $12.46 $11.84 $13.6271022 $40.88 $38.84 $44.6771022 TC $26.57 $25.24 $29.0371022 26 $14.31 $13.59 $15.6371023 26 $17.59 $16.71 $19.2271023 TC $32.96 $31.31 $36.0171023 $50.56 $48.03 $55.2371030 TC $27.92 $26.52 $30.50

71030 26 $14.31 $13.59 $15.6371030 $42.23 $40.12 $46.1471034 $75.75 $71.96 $82.7571034 TC $54.16 $51.45 $59.1771034 26 $21.59 $20.51 $23.5971035 $27.93 $26.53 $30.5171035 TC $19.51 $18.53 $21.3171035 26 $8.42 $8.00 $9.2071040 TC $55.17 $52.41 $60.2771040 26 $26.76 $25.42 $29.2371040 $81.93 $77.83 $89.5071060 TC $82.75 $78.61 $90.4071060 26 $34.13 $32.42 $37.2871060 $116.88 $111.04 $127.7071090 26 $26.98 $25.63 $29.4771100 $30.45 $28.93 $33.2771100 TC $20.18 $19.17 $22.0571100 26 $10.27 $9.76 $11.2271101 26 $12.46 $11.84 $13.6271101 $36.00 $34.20 $39.3371101 TC $23.54 $22.36 $25.7171110 26 $12.46 $11.84 $13.6271110 $39.36 $37.39 $43.0071110 TC $26.91 $25.56 $29.3971111 $46.98 $44.63 $51.3271111 TC $32.29 $30.68 $35.2871111 26 $14.69 $13.96 $16.0571120 $31.71 $30.12 $34.6471120 TC $22.20 $21.09 $24.2571120 26 $9.51 $9.03 $10.3871130 $35.16 $33.40 $38.4171130 TC $24.89 $23.65 $27.2071130 26 $10.27 $9.76 $11.2271250 $261.41 $248.34 $285.5971250 TC $207.88 $197.49 $227.1171250 26 $53.53 $50.85 $58.4871260 $308.85 $293.41 $337.4271260 TC $251.28 $238.72 $274.5371260 26 $57.57 $54.69 $62.8971270 $379.33 $360.36 $414.4171270 TC $315.53 $299.75 $344.7171270 26 $63.80 $60.61 $69.7071275 26 $89.09 $84.64 $97.3471275 $503.24 $478.08 $549.7971275 TC $414.15 $393.44 $452.4671550 26 $67.13 $63.77 $73.3471550 TC $425.24 $403.98 $464.5871550 $492.36 $467.74 $537.9071551 $575.85 $547.06 $629.12

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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PROCEDURECODE/MOD

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New Mexico Disclosure

71551 TC $495.55 $470.77 $541.3971551 26 $80.30 $76.29 $87.7371552 $929.46 $882.99 $1,015.4471552 TC $824.96 $783.71 $901.2771552 26 $104.50 $99.28 $114.1771555 $505.45 $480.18 $552.2171555 26 $84.30 $80.09 $92.1071555 TC $421.16 $400.10 $460.1272010 TC $38.68 $36.75 $42.2672010 26 $20.54 $19.51 $22.4472010 $59.22 $56.26 $64.7072020 $21.41 $20.34 $23.3972020 TC $14.46 $13.74 $15.8072020 26 $6.94 $6.59 $7.5872040 $32.47 $30.85 $35.4872040 TC $22.20 $21.09 $24.2572040 26 $10.27 $9.76 $11.2272050 $46.60 $44.27 $50.9172050 TC $32.29 $30.68 $35.2872050 26 $14.31 $13.59 $15.6372052 $57.53 $54.65 $62.8572052 TC $40.70 $38.67 $44.4772052 26 $16.83 $15.99 $18.3972069 $29.11 $27.65 $31.8072069 TC $18.50 $17.58 $20.2272069 26 $10.61 $10.08 $11.5972070 $32.47 $30.85 $35.4872070 TC $22.20 $21.09 $24.2572070 26 $10.27 $9.76 $11.2272072 26 $10.27 $9.76 $11.2272072 TC $25.56 $24.28 $27.9272072 $35.83 $34.04 $39.1572074 $42.22 $40.11 $46.1372074 TC $31.95 $30.35 $34.9072074 26 $10.27 $9.76 $11.2272080 $33.48 $31.81 $36.5872080 TC $23.21 $22.05 $25.3672080 26 $10.27 $9.76 $11.2272090 26 $12.84 $12.20 $14.0372090 $38.40 $36.48 $41.9572090 TC $25.56 $24.28 $27.9272100 26 $10.27 $9.76 $11.2272100 $34.49 $32.77 $37.6972100 TC $24.22 $23.01 $26.4672110 $47.61 $45.23 $52.0172110 TC $33.30 $31.64 $36.3972110 26 $14.31 $13.59 $15.6372114 $60.56 $57.53 $66.1672114 TC $43.73 $41.54 $47.77

72114 26 $16.83 $15.99 $18.3972120 TC $32.63 $31.00 $35.6572120 $42.89 $40.75 $46.8672120 26 $10.27 $9.76 $11.2272125 26 $53.53 $50.85 $58.4872125 $261.41 $248.34 $285.5972125 TC $207.88 $197.49 $227.1172126 $307.75 $292.36 $336.2172126 TC $251.28 $238.72 $274.5372126 26 $56.48 $53.66 $61.7172127 $373.52 $354.84 $408.0772127 TC $314.52 $298.79 $343.6172127 26 $59.00 $56.05 $64.4672128 26 $53.53 $50.85 $58.4872128 $261.41 $248.34 $285.5972128 TC $207.88 $197.49 $227.1172129 TC $251.28 $238.72 $274.5372129 $307.75 $292.36 $336.2172129 26 $56.48 $53.66 $61.7172130 TC $314.18 $298.47 $343.2472130 26 $59.00 $56.05 $64.4672130 $373.18 $354.52 $407.7072131 TC $207.88 $197.49 $227.1172131 26 $53.53 $50.85 $58.4872131 $261.41 $248.34 $285.5972132 $307.75 $292.36 $336.2172132 TC $251.28 $238.72 $274.5372132 26 $56.48 $53.66 $61.7172133 $374.86 $356.12 $409.5472133 TC $315.86 $300.07 $345.0872133 26 $59.00 $56.05 $64.4672141 TC $398.27 $378.36 $435.1172141 26 $74.07 $70.37 $80.9372141 $472.34 $448.72 $516.0372142 $571.80 $543.21 $624.6972142 TC $482.37 $458.25 $526.9972142 26 $89.43 $84.96 $97.7072146 $505.31 $480.04 $552.0572146 TC $431.24 $409.68 $471.1372146 26 $74.07 $70.37 $80.9372147 $554.97 $527.22 $606.3072147 TC $465.88 $442.59 $508.9872147 26 $89.09 $84.64 $97.3472148 $500.13 $475.12 $546.3972148 TC $431.24 $409.68 $471.1372148 26 $68.89 $65.45 $75.2772149 $565.53 $537.25 $617.8472149 TC $482.71 $458.57 $527.3672149 26 $82.82 $78.68 $90.48

72156 $926.42 $880.10 $1,012.1272156 TC $807.61 $767.23 $882.3172156 26 $118.81 $112.87 $129.8072157 $912.96 $867.31 $997.4172157 TC $794.49 $754.77 $867.9972157 26 $118.47 $112.55 $129.4372158 26 $108.92 $103.47 $118.9972158 $916.53 $870.70 $1,001.3172158 TC $807.61 $767.23 $882.3172170 $25.53 $24.25 $27.8972170 TC $17.49 $16.62 $19.1172170 26 $8.04 $7.64 $8.7972190 $34.44 $32.72 $37.6372190 TC $24.55 $23.32 $26.8272190 26 $9.89 $9.40 $10.8172191 26 $83.96 $79.76 $91.7272191 $486.33 $462.01 $531.3172191 TC $402.37 $382.25 $439.5972192 26 $50.59 $48.06 $55.2772192 $255.10 $242.35 $278.7072192 TC $204.52 $194.29 $223.4372193 $295.39 $280.62 $322.7172193 TC $241.86 $229.77 $264.2472193 26 $53.53 $50.85 $58.4872194 $362.59 $344.46 $396.1372194 TC $306.11 $290.80 $334.4272194 26 $56.48 $53.66 $61.7172195 26 $67.46 $64.09 $73.7072195 TC $409.42 $388.95 $447.2972195 $476.88 $453.04 $521.0072196 TC $476.03 $452.23 $520.0672196 26 $80.30 $76.29 $87.7372196 $556.33 $528.51 $607.7972197 $908.86 $863.42 $992.9372197 TC $804.36 $764.14 $878.7672197 26 $104.50 $99.28 $114.1772198 26 $83.24 $79.08 $90.9472198 $501.37 $476.30 $547.7572198 TC $418.13 $397.22 $456.8072200 $26.20 $24.89 $28.6272200 26 $8.04 $7.64 $8.7972200 TC $18.17 $17.26 $19.8572202 26 $8.80 $8.36 $9.6172202 TC $22.54 $21.41 $24.6272202 $31.33 $29.76 $34.2272220 26 $8.04 $7.64 $8.7972220 TC $19.84 $18.85 $21.6872220 $27.88 $26.49 $30.4672240 26 $41.83 $39.74 $45.70

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

72240 TC $145.98 $138.68 $159.4872240 $187.81 $178.42 $205.1872255 26 $41.16 $39.10 $44.9772255 $173.69 $165.01 $189.7672255 TC $132.53 $125.90 $144.7972265 26 $38.17 $36.26 $41.7072265 TC $127.81 $121.42 $139.6372265 $165.98 $157.68 $181.3372270 26 $61.28 $58.22 $66.9572270 $254.01 $241.31 $277.5172270 TC $192.73 $183.09 $210.5572275 $106.80 $101.46 $116.6872275 26 $33.83 $32.14 $36.9672275 TC $72.96 $69.31 $79.7172285 26 $53.19 $50.53 $58.1172285 TC $235.10 $223.35 $256.8572285 $288.29 $273.88 $314.9672291 26 $63.53 $60.35 $69.4072292 26 $64.81 $61.57 $70.8172295 26 $39.17 $37.21 $42.7972295 TC $221.32 $210.25 $241.7972295 $260.49 $247.47 $284.5973000 TC $17.83 $16.94 $19.4873000 26 $7.32 $6.95 $7.9973000 $25.15 $23.89 $27.4773010 26 $8.04 $7.64 $8.7973010 $26.20 $24.89 $28.6273010 TC $18.17 $17.26 $19.8573020 26 $6.94 $6.59 $7.5873020 $22.75 $21.61 $24.8573020 TC $15.81 $15.02 $17.2773030 $28.26 $26.85 $30.8873030 TC $19.84 $18.85 $21.6873030 26 $8.42 $8.00 $9.2073040 $98.62 $93.69 $107.7473040 TC $73.33 $69.66 $80.1173040 26 $25.29 $24.03 $27.6373050 $33.06 $31.41 $36.1273050 TC $23.54 $22.36 $25.7173050 26 $9.51 $9.03 $10.3873060 TC $19.84 $18.85 $21.6873060 $27.88 $26.49 $30.4673060 26 $8.04 $7.64 $8.7973070 $24.77 $23.53 $27.0673070 TC $17.83 $16.94 $19.4873070 26 $6.94 $6.59 $7.5873080 $29.56 $28.08 $32.2973080 TC $21.53 $20.45 $23.5273080 26 $8.04 $7.64 $8.79

73085 $95.59 $90.81 $104.4373085 TC $70.30 $66.79 $76.8173085 26 $25.29 $24.03 $27.6373090 $25.15 $23.89 $27.4773090 TC $17.83 $16.94 $19.4873090 26 $7.32 $6.95 $7.9973092 $24.82 $23.58 $27.1273092 TC $17.49 $16.62 $19.1173092 26 $7.32 $6.95 $7.9973100 $24.82 $23.58 $27.1273100 TC $17.49 $16.62 $19.1173100 26 $7.32 $6.95 $7.9973110 $27.89 $26.50 $30.4873110 TC $19.85 $18.86 $21.6973110 26 $8.04 $7.64 $8.7973115 $86.18 $81.87 $94.1573115 26 $25.29 $24.03 $27.6373115 TC $60.88 $57.84 $66.5273120 $24.48 $23.26 $26.7573120 TC $17.16 $16.30 $18.7573120 26 $7.32 $6.95 $7.9973130 $26.88 $25.54 $29.3773130 TC $18.84 $17.90 $20.5973130 26 $8.04 $7.64 $8.7973140 $22.71 $21.57 $24.8173140 TC $16.48 $15.66 $18.0173140 26 $6.23 $5.92 $6.8173200 $232.24 $220.63 $253.7273200 TC $181.65 $172.57 $198.4673200 26 $50.59 $48.06 $55.2773201 $272.86 $259.22 $298.1073201 TC $219.32 $208.35 $239.6073201 26 $53.53 $50.85 $58.4873202 $338.37 $321.45 $369.6773202 TC $281.89 $267.80 $307.9773202 26 $56.48 $53.66 $61.7173206 26 $83.96 $79.76 $91.7273206 $455.03 $432.28 $497.1273206 TC $371.07 $352.52 $405.4073218 26 $62.33 $59.21 $68.0973218 TC $410.45 $389.93 $448.4273218 $472.78 $449.14 $516.5173219 $549.53 $522.05 $600.3673219 TC $474.36 $450.64 $518.2473219 26 $75.16 $71.40 $82.1173220 $902.74 $857.60 $986.2473220 TC $803.04 $762.89 $877.3273220 26 $99.70 $94.72 $108.9373221 26 $62.33 $59.21 $68.09

73221 $464.03 $440.83 $506.9573221 TC $401.70 $381.62 $438.8673222 26 $75.16 $71.40 $82.1173222 $540.78 $513.74 $590.8073222 TC $465.61 $442.33 $508.6873223 $891.30 $846.74 $973.7573223 TC $791.60 $752.02 $864.8273223 26 $99.70 $94.72 $108.9373500 $24.18 $22.97 $26.4273500 TC $16.15 $15.34 $17.6473500 26 $8.04 $7.64 $8.7973510 $31.42 $29.85 $34.3373510 TC $21.53 $20.45 $23.5273510 26 $9.89 $9.40 $10.8173520 $35.96 $34.16 $39.2873520 TC $23.88 $22.69 $26.0973520 26 $12.08 $11.48 $13.2073525 26 $25.63 $24.35 $28.0073525 $95.93 $91.13 $104.8073525 TC $70.30 $66.79 $76.8173530 26 $13.55 $12.87 $14.8073540 TC $21.86 $20.77 $23.8973540 26 $9.51 $9.03 $10.3873540 $31.37 $29.80 $34.2773542 $91.72 $87.13 $100.2073542 TC $65.25 $61.99 $71.2973542 26 $26.47 $25.15 $28.9273550 $27.88 $26.49 $30.4673550 TC $19.84 $18.85 $21.6873550 26 $8.04 $7.64 $8.7973560 $26.20 $24.89 $28.6273560 26 $8.04 $7.64 $8.7973560 TC $18.17 $17.26 $19.8573562 26 $8.42 $8.00 $9.2073562 $29.61 $28.13 $32.3573562 TC $21.19 $20.13 $23.1573564 $33.81 $32.12 $36.9473564 TC $23.54 $22.36 $25.7173564 26 $10.27 $9.76 $11.2273565 26 $8.04 $7.64 $8.7973565 $25.87 $24.58 $28.2773565 TC $17.83 $16.94 $19.4873580 26 $25.29 $24.03 $27.6373580 $114.09 $108.39 $124.6573580 TC $88.80 $84.36 $97.0173590 $25.87 $24.58 $28.2773590 TC $17.83 $16.94 $19.4873590 26 $8.04 $7.64 $8.7973592 26 $7.32 $6.95 $7.99

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

73592 $24.82 $23.58 $27.1273592 TC $17.49 $16.62 $19.1173600 $24.48 $23.26 $26.7573600 TC $17.16 $16.30 $18.7573600 26 $7.32 $6.95 $7.9973610 $27.21 $25.85 $29.7373610 TC $19.18 $18.22 $20.9573610 26 $8.04 $7.64 $8.7973615 $96.60 $91.77 $105.5473615 TC $70.97 $67.42 $77.5373615 26 $25.63 $24.35 $28.0073620 TC $17.16 $16.30 $18.7573620 $24.48 $23.26 $26.7573620 26 $7.32 $6.95 $7.9973630 TC $18.84 $17.90 $20.5973630 26 $8.04 $7.64 $8.7973630 $26.88 $25.54 $29.3773650 $24.14 $22.93 $26.3773650 TC $16.82 $15.98 $18.3873650 26 $7.32 $6.95 $7.9973660 $22.37 $21.25 $24.4473660 TC $16.15 $15.34 $17.6473660 26 $6.23 $5.92 $6.8173700 26 $50.59 $48.06 $55.2773700 $232.24 $220.63 $253.7273700 TC $181.65 $172.57 $198.4673701 26 $53.53 $50.85 $58.4873701 $273.53 $259.85 $298.8373701 TC $220.00 $209.00 $240.3573702 $339.05 $322.10 $370.4273702 TC $282.57 $268.44 $308.7173702 26 $56.48 $53.66 $61.7173706 $471.19 $447.63 $514.7773706 TC $382.85 $363.71 $418.2773706 26 $88.34 $83.92 $96.5173718 26 $62.33 $59.21 $68.0973718 $469.41 $445.94 $512.8373718 TC $407.08 $386.73 $444.7473719 26 $74.83 $71.09 $81.7573719 $548.52 $521.09 $599.2573719 TC $473.69 $450.01 $517.5173720 $902.07 $856.97 $985.5273720 TC $802.71 $762.57 $876.9673720 26 $99.36 $94.39 $108.5573721 $466.38 $443.06 $509.5273721 TC $404.05 $383.85 $441.4373721 26 $62.33 $59.21 $68.0973722 TC $467.63 $444.25 $510.8973722 26 $75.16 $71.40 $82.11

73722 $542.80 $515.66 $593.0173723 $890.96 $846.41 $973.3773723 TC $791.26 $751.70 $864.4673723 26 $99.70 $94.72 $108.9373725 $503.14 $477.98 $549.6873725 TC $418.80 $397.86 $457.5473725 26 $84.34 $80.12 $92.1474000 $25.57 $24.29 $27.9374000 TC $17.16 $16.30 $18.7574000 26 $8.42 $8.00 $9.2074010 $32.51 $30.88 $35.5174010 TC $21.53 $20.45 $23.5274010 26 $10.98 $10.43 $11.9974020 $34.99 $33.24 $38.2374020 TC $22.54 $21.41 $24.6274020 26 $12.46 $11.84 $13.6274022 $41.60 $39.52 $45.4574022 TC $26.91 $25.56 $29.3974022 26 $14.69 $13.96 $16.0574150 $253.13 $240.47 $276.5474150 TC $198.13 $188.22 $216.4574150 26 $55.01 $52.26 $60.1074160 $310.62 $295.09 $339.3574160 26 $59.00 $56.05 $64.4674160 TC $251.62 $239.04 $274.9074170 $387.16 $367.80 $422.9774170 TC $322.27 $306.16 $352.0874170 26 $64.90 $61.66 $70.9174175 $497.44 $472.57 $543.4674175 TC $409.44 $388.97 $447.3274175 26 $88.00 $83.60 $96.1474181 26 $67.13 $63.77 $73.3474181 $460.73 $437.69 $503.3474181 TC $393.60 $373.92 $430.0174182 26 $80.30 $76.29 $87.7374182 $571.47 $542.90 $624.3474182 TC $491.18 $466.62 $536.6174183 $909.20 $863.74 $993.3074183 TC $804.70 $764.47 $879.1474183 26 $104.50 $99.28 $114.1774185 26 $83.24 $79.08 $90.9474185 $501.71 $476.62 $548.1174185 TC $418.46 $397.54 $457.1774190 26 $22.35 $21.23 $24.4174210 $61.91 $58.81 $67.6374210 TC $45.08 $42.83 $49.2574210 26 $16.83 $15.99 $18.3974220 $68.01 $64.61 $74.3074220 TC $46.76 $44.42 $51.08

74220 26 $21.25 $20.19 $23.2274230 26 $24.58 $23.35 $26.8574230 TC $49.45 $46.98 $54.0374230 $74.03 $70.33 $80.8874235 26 $55.34 $52.57 $60.4674240 TC $55.84 $53.05 $61.0174240 26 $31.90 $30.31 $34.8674240 $87.74 $83.35 $95.8574241 26 $31.90 $30.31 $34.8674241 TC $58.87 $55.93 $64.3274241 $90.77 $86.23 $99.1674245 TC $93.52 $88.84 $102.1774245 $135.69 $128.91 $148.2574245 26 $42.17 $40.06 $46.0774246 $97.16 $92.30 $106.1574246 TC $65.26 $62.00 $71.3074246 26 $31.90 $30.31 $34.8674247 26 $31.90 $30.31 $34.8674247 $101.53 $96.45 $110.9274247 TC $69.63 $66.15 $76.0774249 TC $101.59 $96.51 $110.9974249 26 $42.17 $40.06 $46.0774249 $143.76 $136.57 $157.0674250 TC $53.82 $51.13 $58.8074250 $75.46 $71.69 $82.4474250 26 $21.63 $20.55 $23.6374251 $145.29 $138.03 $158.7374251 TC $113.39 $107.72 $123.8874251 26 $31.90 $30.31 $34.8674260 TC $105.31 $100.04 $115.0574260 26 $23.11 $21.95 $25.2474260 $128.41 $121.99 $140.2974270 26 $31.90 $30.31 $34.8674270 TC $73.33 $69.66 $80.1174270 $105.23 $99.97 $114.9774280 26 $45.50 $43.23 $49.7174280 TC $97.22 $92.36 $106.2174280 $142.71 $135.57 $155.9174283 26 $93.51 $88.83 $102.1574283 TC $91.83 $87.24 $100.3374283 $185.34 $176.07 $202.4874290 $46.31 $43.99 $50.5974290 TC $31.62 $30.04 $34.5574290 26 $14.69 $13.96 $16.0574291 $33.40 $31.73 $36.4974291 TC $23.89 $22.70 $26.1174291 26 $9.51 $9.03 $10.3874300 26 $16.83 $15.99 $18.3974301 26 $9.89 $9.40 $10.81

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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PROCEDURECODE/MOD

PARFEE

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PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

74305 26 $19.78 $18.79 $21.6174320 $125.87 $119.58 $137.5274320 TC $100.57 $95.54 $109.8774320 26 $25.29 $24.03 $27.6374327 $102.24 $97.13 $111.7074327 TC $69.96 $66.46 $76.4374327 26 $32.28 $30.67 $35.2774328 26 $32.62 $30.99 $35.6474329 26 $32.62 $30.99 $35.6474330 26 $41.79 $39.70 $45.6674340 26 $25.29 $24.03 $27.6374350 TC $100.91 $95.86 $110.2474350 26 $34.85 $33.11 $38.0874350 $135.75 $128.96 $148.3074355 26 $34.85 $33.11 $38.0874360 26 $25.97 $24.67 $28.3774363 26 $40.70 $38.67 $44.4774400 $88.32 $83.90 $96.4974400 TC $65.59 $62.31 $71.6674400 26 $22.73 $21.59 $24.8374410 $96.06 $91.26 $104.9574410 TC $73.33 $69.66 $80.1174410 26 $22.73 $21.59 $24.8374415 $105.14 $99.88 $114.8674415 TC $82.41 $78.29 $90.0374415 26 $22.73 $21.59 $24.8374420 26 $16.83 $15.99 $18.3974425 26 $16.83 $15.99 $18.3974430 $58.42 $55.50 $63.8374430 TC $43.39 $41.22 $47.4074430 26 $15.02 $14.27 $16.4174440 26 $17.93 $17.03 $19.5874440 TC $47.43 $45.06 $51.8274440 $65.36 $62.09 $71.4074445 26 $54.49 $51.77 $59.5474450 26 $15.74 $14.95 $17.1974455 $75.61 $71.83 $82.6074455 TC $59.87 $56.88 $65.4174455 26 $15.74 $14.95 $17.1974470 26 $24.96 $23.71 $27.2774475 $150.75 $143.21 $164.6974475 TC $125.46 $119.19 $137.0774475 26 $25.29 $24.03 $27.6374480 $150.75 $143.21 $164.6974480 TC $125.46 $119.19 $137.0774480 26 $25.29 $24.03 $27.6374485 $127.21 $120.85 $138.9874485 TC $101.92 $96.82 $111.3474485 26 $25.29 $24.03 $27.63

74710 $49.08 $46.63 $53.6274710 TC $32.96 $31.31 $36.0174710 26 $16.12 $15.31 $17.6174740 $66.37 $63.05 $72.5174740 TC $48.44 $46.02 $52.9274740 26 $17.93 $17.03 $19.5874742 26 $28.24 $26.83 $30.8574775 26 $28.95 $27.50 $31.6375552 TC $452.12 $429.51 $493.9475552 26 $74.74 $71.00 $81.6575552 $526.86 $500.52 $575.6075553 TC $493.51 $468.83 $539.1575553 26 $94.78 $90.04 $103.5575553 $588.29 $558.88 $642.7175554 26 $87.75 $83.36 $95.8675554 $606.16 $575.85 $662.2375554 TC $518.41 $492.49 $566.3675555 26 $84.68 $80.45 $92.5275555 $607.46 $577.09 $663.6575555 TC $522.79 $496.65 $571.1575600 $415.93 $395.13 $454.4075600 TC $391.52 $371.94 $427.7375600 26 $24.41 $23.19 $26.6775605 $420.11 $399.10 $458.9775605 TC $365.27 $347.01 $399.0675605 26 $54.84 $52.10 $59.9275625 $417.75 $396.86 $456.3975625 TC $363.59 $345.41 $397.2275625 26 $54.16 $51.45 $59.1775630 26 $86.22 $81.91 $94.2075630 $465.95 $442.65 $509.0575630 TC $379.73 $360.74 $414.8575635 $622.17 $591.06 $679.7275635 26 $111.78 $106.19 $122.1275635 TC $510.40 $484.88 $557.6175650 26 $69.94 $66.44 $76.4175650 TC $363.59 $345.41 $397.2275650 $433.54 $411.86 $473.6475658 26 $62.87 $59.73 $68.6975658 TC $367.29 $348.93 $401.2775658 $430.16 $408.65 $469.9575660 26 $61.86 $58.77 $67.5975660 $429.49 $408.02 $469.2275660 TC $367.63 $349.25 $401.6475662 $455.04 $432.29 $497.1375662 26 $79.33 $75.36 $86.6675662 TC $375.71 $356.92 $410.4675665 26 $62.53 $59.40 $68.3175665 $431.50 $409.93 $471.42

75665 TC $368.98 $350.53 $403.1175671 TC $375.71 $356.92 $410.4675671 26 $77.65 $73.77 $84.8475671 $453.35 $430.68 $495.2875676 $429.15 $407.69 $468.8475676 TC $367.29 $348.93 $401.2775676 26 $61.86 $58.77 $67.5975680 26 $77.65 $73.77 $84.8475680 $449.32 $426.85 $490.8875680 TC $371.67 $353.09 $406.0575685 26 $61.53 $58.45 $67.2275685 TC $366.96 $348.61 $400.9075685 $428.48 $407.06 $468.1275705 $468.79 $445.35 $512.1575705 TC $366.28 $347.97 $400.1775705 26 $102.51 $97.38 $111.9975710 $423.81 $402.62 $463.0175710 TC $368.98 $350.53 $403.1175710 26 $54.83 $52.09 $59.9075716 26 $61.86 $58.77 $67.5975716 $437.57 $415.69 $478.0475716 TC $375.71 $356.92 $410.4675722 $422.47 $401.35 $461.5575722 TC $367.63 $349.25 $401.6475722 26 $54.84 $52.10 $59.9275724 $449.36 $426.89 $490.9275724 TC $376.38 $357.56 $411.1975724 26 $72.98 $69.33 $79.7375726 $419.44 $398.47 $458.2475726 TC $366.28 $347.97 $400.1775726 26 $53.15 $50.49 $58.0675731 $421.45 $400.38 $460.4475731 TC $367.63 $349.25 $401.6475731 26 $53.82 $51.13 $58.8075733 $440.60 $418.57 $481.3675733 TC $377.73 $358.84 $412.6775733 26 $62.87 $59.73 $68.6975736 $421.45 $400.38 $460.4475736 TC $367.63 $349.25 $401.6475736 26 $53.82 $51.13 $58.8075741 26 $61.19 $58.13 $66.8575741 $422.43 $401.31 $461.5175741 TC $361.24 $343.18 $394.6675743 26 $76.64 $72.81 $83.7375743 $439.89 $417.90 $480.5975743 TC $363.26 $345.10 $396.8775746 $417.75 $396.86 $456.3975746 TC $364.60 $346.37 $398.3375746 26 $53.15 $50.49 $58.06

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

75756 $428.19 $406.78 $467.8075756 TC $371.33 $352.76 $405.6775756 26 $56.86 $54.02 $62.1275774 26 $16.83 $15.99 $18.3975774 $376.05 $357.25 $410.8475774 TC $359.22 $341.26 $392.4575790 26 $85.05 $80.80 $92.9275790 $142.24 $135.13 $155.4075790 TC $57.19 $54.33 $62.4875801 26 $39.08 $37.13 $42.7075803 26 $53.57 $50.89 $58.5275805 26 $38.08 $36.18 $41.6175807 26 $53.91 $51.21 $58.8975809 $59.31 $56.34 $64.7975809 TC $37.68 $35.80 $41.1775809 26 $21.63 $20.55 $23.6375810 26 $52.82 $50.18 $57.7175820 26 $32.95 $31.30 $36.0075820 TC $48.44 $46.02 $52.9275820 $81.39 $77.32 $88.9275822 $111.68 $106.10 $122.0275822 TC $62.57 $59.44 $68.3675822 26 $49.11 $46.65 $53.6575825 $413.71 $393.02 $451.9775825 TC $360.23 $342.22 $393.5575825 26 $53.48 $50.81 $58.4375827 26 $52.82 $50.18 $57.7175827 $413.38 $392.71 $451.6275827 TC $360.56 $342.53 $393.9175831 26 $53.15 $50.49 $58.0675831 $414.39 $393.67 $452.7275831 TC $361.24 $343.18 $394.6675833 $435.55 $413.77 $475.8475833 TC $365.61 $347.33 $399.4375833 26 $69.94 $66.44 $76.4175840 26 $54.49 $51.77 $59.5475840 $417.41 $396.54 $456.0275840 TC $362.92 $344.77 $396.4975842 $433.87 $412.18 $474.0175842 TC $364.94 $346.69 $398.6975842 26 $68.93 $65.48 $75.3075860 $418.43 $397.51 $457.1475860 TC $363.93 $345.73 $397.5975860 26 $54.50 $51.78 $59.5575870 TC $362.58 $344.45 $396.1275870 $416.41 $395.59 $454.9375870 26 $53.83 $51.14 $58.8175872 TC $368.64 $350.21 $402.7475872 26 $56.83 $53.99 $62.09

75872 $425.47 $404.20 $464.8375880 $81.06 $77.01 $88.5675880 TC $48.44 $46.02 $52.9275880 26 $32.62 $30.99 $35.6475885 26 $66.75 $63.41 $72.9275885 $427.65 $406.27 $467.2175885 TC $360.90 $342.86 $394.2975887 26 $67.08 $63.73 $73.2975887 $429.67 $408.19 $469.4275887 TC $362.58 $344.45 $396.1275889 $413.72 $393.03 $451.9875889 TC $360.90 $342.86 $394.2975889 26 $52.82 $50.18 $57.7175891 $413.72 $393.03 $451.9875891 TC $360.90 $342.86 $394.2975891 26 $52.82 $50.18 $57.7175893 TC $361.24 $343.18 $394.6675893 $386.53 $367.20 $422.2875893 26 $25.29 $24.03 $27.6375894 26 $61.52 $58.44 $67.2175896 26 $61.87 $58.78 $67.6075898 26 $76.93 $73.08 $84.0475900 26 $23.06 $21.91 $25.2075901 $115.36 $109.59 $126.0375901 TC $92.63 $88.00 $101.2075901 26 $22.73 $21.59 $24.8375902 26 $18.31 $17.39 $20.0075902 $91.08 $86.53 $99.5175902 TC $72.78 $69.14 $79.5175940 26 $25.96 $24.66 $28.3675945 26 $19.69 $18.71 $21.5275946 26 $20.02 $19.02 $21.8775952 26 $215.91 $205.11 $235.8875953 26 $65.38 $62.11 $71.4375954 26 $106.80 $101.46 $116.6875956 26 $344.89 $327.65 $376.8075957 26 $295.67 $280.89 $323.0275958 26 $196.89 $187.05 $215.1175959 26 $172.45 $163.83 $188.4075960 26 $39.47 $37.50 $43.1375961 TC $308.77 $293.33 $337.3375961 26 $196.16 $186.35 $214.3075961 $504.93 $479.68 $551.6375962 $478.01 $454.11 $522.2375962 TC $452.38 $429.76 $494.2275962 26 $25.63 $24.35 $28.0075964 $261.69 $248.61 $285.9075964 TC $244.53 $232.30 $267.1575964 26 $17.17 $16.31 $18.76

75966 $517.95 $492.05 $565.8675966 TC $454.74 $432.00 $496.8075966 26 $63.21 $60.05 $69.0675968 26 $17.51 $16.63 $19.1275968 TC $244.86 $232.62 $267.5175968 $262.37 $249.25 $286.6475970 26 $39.18 $37.22 $42.8075978 $474.98 $451.23 $518.9175978 TC $449.69 $427.21 $491.2975978 26 $25.29 $24.03 $27.6375980 26 $66.75 $63.41 $72.9275982 26 $66.75 $63.41 $72.9275984 $102.67 $97.54 $112.1775984 TC $69.29 $65.83 $75.7075984 26 $33.37 $31.70 $36.4675989 $154.90 $147.16 $169.2375989 TC $99.90 $94.91 $109.1575989 26 $55.01 $52.26 $60.1075992 26 $26.30 $24.99 $28.7475993 26 $17.51 $16.63 $19.1275994 26 $63.88 $60.69 $69.7975995 26 $62.54 $59.41 $68.3275996 26 $17.17 $16.31 $18.7676000 $64.89 $61.65 $70.9076000 TC $57.19 $54.33 $62.4876000 26 $7.70 $7.32 $8.4276001 26 $31.81 $30.22 $34.7576010 $26.25 $24.94 $28.6876010 TC $17.83 $16.94 $19.4876010 26 $8.42 $8.00 $9.2076080 $60.95 $57.90 $66.5976080 TC $35.65 $33.87 $38.9576080 26 $25.29 $24.03 $27.6376098 $20.78 $19.74 $22.7076098 TC $13.46 $12.79 $14.7176098 26 $7.32 $6.95 $7.9976100 $87.99 $83.59 $96.1376100 TC $60.89 $57.85 $66.5376100 26 $27.10 $25.75 $29.6176101 $107.51 $102.13 $117.4576101 TC $80.41 $76.39 $87.8576101 26 $27.10 $25.75 $29.6176102 $137.11 $130.25 $149.7976102 TC $110.01 $104.51 $120.1976102 26 $27.10 $25.75 $29.6176120 $60.65 $57.62 $66.2676120 TC $42.72 $40.58 $46.6776120 26 $17.93 $17.03 $19.5876125 26 $12.46 $11.84 $13.62

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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NONPAR CHARGEFEE FEE

New Mexico Disclosure

76150 $16.82 $15.98 $18.3876350 $15.36 $14.59 $16.7876376 26 $9.84 $9.35 $10.7576376 TC $99.59 $94.61 $108.8076376 $109.43 $103.96 $119.5576377 $143.90 $136.71 $157.2276377 TC $105.58 $100.30 $115.3576377 26 $38.32 $36.40 $41.8676380 $174.63 $165.90 $190.7976380 TC $129.51 $123.03 $141.4876380 26 $45.12 $42.86 $49.2976506 26 $31.34 $29.77 $34.2476506 $90.88 $86.34 $99.2976506 TC $59.54 $56.56 $65.0476510 26 $75.89 $72.10 $82.9276510 $147.89 $140.50 $161.5876510 TC $72.00 $68.40 $78.6676511 $108.57 $103.14 $118.6176511 TC $62.24 $59.13 $68.0076511 26 $46.34 $44.02 $50.6276512 $102.51 $97.38 $111.9976512 TC $56.17 $53.36 $61.3676512 26 $46.34 $44.02 $50.6276513 $85.25 $80.99 $93.1476513 TC $52.80 $50.16 $57.6876513 26 $32.45 $30.83 $35.4576514 $11.40 $10.83 $12.4576514 TC $2.69 $2.56 $2.9476514 26 $8.71 $8.27 $9.5176516 $68.02 $64.62 $74.3176516 TC $41.37 $39.30 $45.2076516 26 $26.64 $25.31 $29.1176519 26 $26.64 $25.31 $29.1176519 $71.38 $67.81 $77.9876519 TC $44.74 $42.50 $48.8876529 26 $27.73 $26.34 $30.2976529 $67.08 $63.73 $73.2976529 TC $39.35 $37.38 $42.9976536 $83.87 $79.68 $91.6376536 TC $58.53 $55.60 $63.9476536 26 $25.34 $24.07 $27.6876604 $73.40 $69.73 $80.1976604 TC $48.44 $46.02 $52.9276604 26 $24.96 $23.71 $27.2776645 TC $43.73 $41.54 $47.7776645 $68.69 $65.26 $75.0576645 26 $24.96 $23.71 $27.2776700 TC $75.35 $71.58 $82.3276700 26 $37.75 $35.86 $41.24

76700 $113.10 $107.45 $123.5776705 $83.32 $79.15 $91.0276705 TC $55.84 $53.05 $61.0176705 26 $27.48 $26.11 $30.0376770 26 $34.47 $32.75 $37.6676770 $109.48 $104.01 $119.6176770 TC $75.01 $71.26 $81.9576775 26 $27.10 $25.75 $29.6176775 $82.94 $78.79 $90.6176775 TC $55.84 $53.05 $61.0176776 $112.89 $107.25 $123.3476776 TC $78.38 $74.46 $85.6376776 26 $34.51 $32.78 $37.7076800 $106.60 $101.27 $116.4676800 TC $55.17 $52.41 $60.2776800 26 $51.43 $48.86 $56.1976801 $120.84 $114.80 $132.0276801 TC $74.67 $70.94 $81.5876801 26 $46.17 $43.86 $50.4476802 $75.49 $71.72 $82.4876802 TC $36.31 $34.49 $39.6676802 26 $39.18 $37.22 $42.8076805 $125.22 $118.96 $136.8076805 TC $79.05 $75.10 $86.3776805 26 $46.17 $43.86 $50.4476810 $90.48 $85.96 $98.8576810 TC $45.03 $42.78 $49.2076810 26 $45.45 $43.18 $49.6676811 TC $124.05 $117.85 $135.5376811 26 $90.35 $85.83 $98.7076811 $214.40 $203.68 $234.2376812 $152.70 $145.07 $166.8376812 TC $68.53 $65.10 $74.8776812 26 $84.17 $79.96 $91.9576813 26 $52.94 $50.29 $57.8376813 $115.83 $110.04 $126.5576813 TC $62.89 $59.75 $68.7176814 26 $44.48 $42.26 $48.6076814 $77.42 $73.55 $84.5876814 TC $32.94 $31.29 $35.9876815 $81.85 $77.76 $89.4276815 TC $51.46 $48.89 $56.2276815 26 $30.38 $28.86 $33.1976816 $88.00 $83.60 $96.1476816 TC $47.77 $45.38 $52.1976816 26 $40.23 $38.22 $43.9576817 $89.64 $85.16 $97.9376817 TC $54.84 $52.10 $59.9276817 26 $34.81 $33.07 $38.03

76818 $109.28 $103.82 $119.3976818 TC $59.54 $56.56 $65.0476818 26 $49.74 $47.25 $54.3476819 $91.40 $86.83 $99.8576819 TC $55.50 $52.73 $60.6476819 26 $35.90 $34.11 $39.2376820 $72.20 $68.59 $78.8876820 TC $48.09 $45.69 $52.5476820 26 $24.11 $22.90 $26.3476821 $91.81 $87.22 $100.3076821 TC $58.52 $55.59 $63.9376821 26 $33.29 $31.63 $36.3776825 26 $78.36 $74.44 $85.6176825 $163.81 $155.62 $178.9676825 TC $85.45 $81.18 $93.3676826 $79.21 $75.25 $86.5476826 TC $40.37 $38.35 $44.1076826 26 $38.85 $36.91 $42.4576827 $81.92 $77.82 $89.4976827 TC $54.82 $52.08 $59.8976827 26 $27.10 $25.75 $29.6176828 26 $27.02 $25.67 $29.5276828 $61.65 $58.57 $67.3676828 TC $34.64 $32.91 $37.8576830 26 $31.90 $30.31 $34.8676830 $94.13 $89.42 $102.8376830 TC $62.23 $59.12 $67.9976831 $96.27 $91.46 $105.1876831 TC $62.56 $59.43 $68.3476831 26 $33.71 $32.02 $36.8276856 $94.80 $90.06 $103.5776856 TC $62.56 $59.43 $68.3476856 26 $32.24 $30.63 $35.2276857 26 $17.93 $17.03 $19.5876857 TC $64.60 $61.37 $70.5876857 $82.52 $78.39 $90.1576870 TC $62.56 $59.43 $68.3476870 26 $30.05 $28.55 $32.8376870 $92.61 $87.98 $101.1876872 26 $32.57 $30.94 $35.5876872 TC $80.40 $76.38 $87.8476872 $112.97 $107.32 $123.4276873 26 $73.18 $69.52 $79.9576873 $155.58 $147.80 $169.9776873 TC $82.40 $78.28 $90.0276880 $90.05 $85.55 $98.3876880 TC $62.91 $59.76 $68.7276880 26 $27.14 $25.78 $29.6576885 $99.72 $94.73 $108.94

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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PROCEDURECODE/MOD

PARFEE

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PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

76885 TC $65.59 $62.31 $71.6676885 26 $34.13 $32.42 $37.2876886 26 $28.62 $27.19 $31.2776886 $84.12 $79.91 $91.9076886 TC $55.50 $52.73 $60.6476930 $89.00 $84.55 $97.2376930 TC $56.51 $53.68 $61.7376930 26 $32.49 $30.87 $35.5076932 26 $32.83 $31.19 $35.8776936 $307.98 $292.58 $336.4776936 TC $213.59 $202.91 $233.3576936 26 $94.38 $89.66 $103.1176937 $31.73 $30.14 $34.6676937 TC $17.13 $16.27 $18.7176937 26 $14.60 $13.87 $15.9576940 26 $99.76 $94.77 $108.9976941 26 $63.67 $60.49 $69.5676942 $142.50 $135.38 $155.6976942 TC $111.36 $105.79 $121.6676942 26 $31.14 $29.58 $34.0276945 26 $31.14 $29.58 $34.0276946 $62.32 $59.20 $68.0876946 TC $44.39 $42.17 $48.5076946 26 $17.93 $17.03 $19.5876948 $61.98 $58.88 $67.7176948 TC $44.39 $42.17 $48.5076948 26 $17.59 $16.71 $19.2276950 $71.17 $67.61 $77.7576950 TC $44.06 $41.86 $48.1476950 26 $27.10 $25.75 $29.6176965 $219.73 $208.74 $240.0576965 TC $156.06 $148.26 $170.5076965 26 $63.67 $60.49 $69.5676970 $63.76 $60.57 $69.6676970 TC $45.08 $42.83 $49.2576970 26 $18.68 $17.75 $20.4176975 26 $38.42 $36.50 $41.9876977 $25.73 $24.44 $28.1176977 TC $23.21 $22.05 $25.3676977 26 $2.52 $2.39 $2.7576998 26 $17.46 $16.59 $19.0877001 $74.77 $71.03 $81.6877001 TC $57.18 $54.32 $62.4777001 26 $17.59 $16.71 $19.2277002 26 $24.62 $23.39 $26.9077002 $68.69 $65.26 $75.0577002 TC $44.06 $41.86 $48.1477003 $66.88 $63.54 $73.0777003 TC $40.36 $38.34 $44.09

77003 26 $26.51 $25.18 $28.9677011 $439.95 $417.95 $480.6477011 TC $383.85 $364.66 $419.3677011 26 $56.10 $53.30 $61.3077012 $291.33 $276.76 $318.2777012 TC $237.80 $225.91 $259.8077012 26 $53.53 $50.85 $58.4877013 26 $48.74 $46.30 $53.2577014 TC $114.71 $108.97 $125.3277014 26 $39.56 $37.58 $43.2277014 $154.27 $146.56 $168.5477021 TC $374.73 $355.99 $409.3977021 26 $70.65 $67.12 $77.1977021 $445.38 $423.11 $486.5877022 26 $53.10 $50.45 $58.0277031 $277.85 $263.96 $303.5577031 TC $203.82 $193.63 $222.6777031 26 $74.02 $70.32 $80.8777032 $64.35 $61.13 $70.3077032 TC $38.68 $36.75 $42.2677032 26 $25.67 $24.39 $28.0577051 $15.35 $14.58 $16.7777051 26 $2.90 $2.76 $3.1777051 TC $12.45 $11.83 $13.6077052 $15.35 $14.58 $16.7777052 TC $12.45 $11.83 $13.6077052 26 $2.90 $2.76 $3.1777053 $91.84 $87.25 $100.3477053 TC $75.00 $71.25 $81.9477053 26 $16.83 $15.99 $18.3977054 $131.53 $124.95 $143.6977054 TC $110.66 $105.13 $120.9077054 26 $20.87 $19.83 $22.8077055 $48.10 $45.70 $52.5677055 TC $39.69 $37.71 $43.3777055 26 $8.40 $7.98 $9.1877056 $89.77 $85.28 $98.0777056 TC $49.79 $47.30 $54.4077056 26 $39.98 $37.98 $43.6877057 $75.33 $71.56 $82.2977057 TC $43.05 $40.90 $47.0477057 26 $32.28 $30.67 $35.2777058 26 $75.21 $71.45 $82.1777058 $720.06 $684.06 $786.6777058 TC $644.85 $612.61 $704.5077059 26 $75.21 $71.45 $82.1777059 TC $813.69 $773.01 $888.9677059 $888.90 $844.46 $971.1377071 $27.13 $25.77 $29.64

77072 $20.57 $19.54 $22.4777072 TC $12.11 $11.50 $13.2377072 26 $8.46 $8.04 $9.2577073 $38.36 $36.44 $41.9177073 TC $25.90 $24.61 $28.3077073 26 $12.46 $11.84 $13.6277074 TC $37.34 $35.47 $40.7977074 26 $20.87 $19.83 $22.8077074 $58.21 $55.30 $63.6077075 TC $55.84 $53.05 $61.0177075 26 $25.29 $24.03 $27.6377075 $81.13 $77.07 $88.6377076 $66.93 $63.58 $73.1277076 TC $34.65 $32.92 $37.8677076 26 $32.28 $30.67 $35.2777077 26 $14.64 $13.91 $16.0077077 $49.29 $46.83 $53.8577077 TC $34.64 $32.91 $37.8577078 $128.76 $122.32 $140.6777078 TC $117.40 $111.53 $128.2677078 26 $11.36 $10.79 $12.4177079 $92.03 $87.43 $100.5477079 TC $81.76 $77.67 $89.3277079 26 $10.27 $9.76 $11.2277080 $99.99 $94.99 $109.2477080 TC $89.80 $85.31 $98.1177080 26 $10.18 $9.67 $11.1277081 TC $25.90 $24.61 $28.3077081 $36.50 $34.68 $39.8877081 26 $10.61 $10.08 $11.5977082 TC $23.54 $22.36 $25.7177082 26 $8.04 $7.64 $8.7977082 $31.58 $30.00 $34.5077083 $32.72 $31.08 $35.7477083 TC $23.21 $22.05 $25.3677083 26 $9.51 $9.03 $10.3877084 26 $74.07 $70.37 $80.9377084 $488.50 $464.08 $533.6977084 TC $414.43 $393.71 $452.7777261 $66.87 $63.53 $73.0677262 $100.58 $95.55 $109.8877263 $149.23 $141.77 $163.0477280 $162.12 $154.01 $177.1177280 TC $129.17 $122.71 $141.1277280 26 $32.95 $31.30 $36.0077285 $264.36 $251.14 $288.8177285 TC $215.62 $204.84 $235.5777285 26 $48.73 $46.29 $53.2377290 TC $284.93 $270.68 $311.28

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

77290 $357.82 $339.93 $390.9277290 26 $72.89 $69.25 $79.6477295 TC $804.53 $764.30 $878.9577295 26 $212.86 $202.22 $232.5577295 $1,017.39 $966.52 $1,111.5077300 $73.35 $69.68 $80.1377300 TC $44.40 $42.18 $48.5177300 26 $28.95 $27.50 $31.6377301 26 $372.98 $354.33 $407.4877301 $1,588.75 $1,509.31 $1,735.7177301 TC $1,215.77 $1,154.98 $1,328.2377305 26 $32.95 $31.30 $36.0077305 $89.12 $84.66 $97.3677305 TC $56.17 $53.36 $61.3677310 $119.70 $113.72 $130.7877310 TC $70.97 $67.42 $77.5377310 26 $48.73 $46.29 $53.2377315 $157.99 $150.09 $172.6077315 TC $85.10 $80.85 $92.9877315 26 $72.89 $69.25 $79.6477321 $163.38 $155.21 $178.4977321 TC $119.07 $113.12 $130.0977321 26 $44.31 $42.09 $48.4077326 $130.38 $123.86 $142.4477326 TC $86.45 $82.13 $94.4577326 26 $43.93 $41.73 $47.9977327 $189.31 $179.84 $206.8277327 TC $124.46 $118.24 $135.9877327 26 $64.85 $61.61 $70.8577328 $269.69 $256.21 $294.6477328 TC $171.89 $163.30 $187.8077328 26 $97.80 $92.91 $106.8577331 $58.15 $55.24 $63.5377331 26 $40.32 $38.30 $44.0577331 TC $17.83 $16.94 $19.4877332 $73.39 $69.72 $80.1877332 TC $47.77 $45.38 $52.1977332 26 $25.63 $24.35 $28.0077333 $92.70 $88.07 $101.2877333 TC $53.47 $50.80 $58.4277333 26 $39.22 $37.26 $42.8577334 26 $58.24 $55.33 $63.6377334 $165.55 $157.27 $180.8677334 TC $107.30 $101.94 $117.2377336 $90.14 $85.63 $98.4777370 $119.75 $113.76 $130.8277371 $1,022.34 $971.22 $1,116.9077372 $776.00 $737.20 $847.7877373 $1,447.04 $1,374.69 $1,580.89

77401 $52.47 $49.85 $57.3377402 $83.43 $79.26 $91.1577403 $80.06 $76.06 $87.4777404 $83.76 $79.57 $91.5177406 $83.76 $79.57 $91.5177407 $102.61 $97.48 $112.1077408 $100.59 $95.56 $109.8977409 $105.63 $100.35 $115.4077411 $105.30 $100.04 $115.0577412 $120.77 $114.73 $131.9477413 $120.77 $114.73 $131.9477414 $128.18 $121.77 $140.0477416 $128.18 $121.77 $140.0477417 $19.17 $18.21 $20.9477418 $569.71 $541.22 $622.4077421 $121.93 $115.83 $133.2077421 TC $103.62 $98.44 $113.2177421 26 $18.31 $17.39 $20.0077422 $158.47 $150.55 $173.1377423 $133.56 $126.88 $145.9177427 $170.57 $162.04 $186.3577431 $88.67 $84.24 $96.8877432 $379.41 $360.44 $414.5177435 $621.18 $590.12 $678.6477470 $409.25 $388.79 $447.1177470 TC $311.45 $295.88 $340.2677470 26 $97.80 $92.91 $106.8577600 26 $71.88 $68.29 $78.5377600 $232.35 $220.73 $253.8477600 TC $160.48 $152.46 $175.3377605 26 $98.46 $93.54 $107.5777605 TC $250.31 $237.79 $273.4677605 $348.77 $331.33 $381.0377610 $294.28 $279.57 $321.5177610 TC $221.39 $210.32 $241.8777610 26 $72.89 $69.25 $79.6477615 $419.46 $398.49 $458.2677615 TC $321.99 $305.89 $351.7777615 26 $97.46 $92.59 $106.4877620 26 $76.22 $72.41 $83.2777620 $235.01 $223.26 $256.7577620 TC $158.79 $150.85 $173.4877750 26 $230.45 $218.93 $251.7777750 TC $60.55 $57.52 $66.1577750 $291.00 $276.45 $317.9277761 26 $174.73 $165.99 $190.8977761 $285.07 $270.82 $311.4477761 TC $110.34 $104.82 $120.5477762 $413.43 $392.76 $451.67

77762 TC $146.00 $138.70 $159.5177762 26 $267.44 $254.07 $292.1877763 $585.19 $555.93 $639.3277763 TC $184.35 $175.13 $201.4077763 26 $400.84 $380.80 $437.9277776 TC $108.32 $102.90 $118.3477776 $320.53 $304.50 $350.1877776 26 $212.21 $201.60 $231.8477777 TC $159.45 $151.48 $174.2077777 26 $349.20 $331.74 $381.5077777 $508.65 $483.22 $555.7077778 $726.44 $690.12 $793.6477778 TC $202.51 $192.38 $221.2477778 26 $523.93 $497.73 $572.3977781 26 $60.80 $57.76 $66.4277781 $642.34 $610.22 $701.7577781 TC $581.54 $552.46 $635.3377782 26 $99.60 $94.62 $108.8177782 $746.43 $709.11 $815.4877782 TC $646.83 $614.49 $706.6677783 $900.20 $855.19 $983.4777783 TC $743.07 $705.92 $811.8177783 26 $157.13 $149.27 $171.6677784 $1,164.12 $1,105.91 $1,271.8077784 TC $919.08 $873.13 $1,004.1077784 26 $245.04 $232.79 $267.7177789 $80.07 $76.07 $87.4877789 TC $26.24 $24.93 $28.6777789 26 $53.82 $51.13 $58.8077790 $71.61 $68.03 $78.2377790 TC $22.88 $21.74 $25.0077790 26 $48.73 $46.29 $53.2378000 $49.50 $47.03 $54.0878000 TC $40.70 $38.67 $44.4778000 26 $8.80 $8.36 $9.6178001 26 $12.08 $11.48 $13.2078001 $64.89 $61.65 $70.9078001 TC $52.81 $50.17 $57.7078003 26 $15.40 $14.63 $16.8278003 $56.11 $53.30 $61.3078003 TC $40.70 $38.67 $44.4778006 $135.42 $128.65 $147.9578006 TC $112.70 $107.07 $123.1378006 26 $22.73 $21.59 $24.8378007 $115.27 $109.51 $125.9478007 TC $92.17 $87.56 $100.6978007 26 $23.11 $21.95 $25.2478010 $100.05 $95.05 $109.3178010 TC $81.74 $77.65 $89.30

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

78010 26 $18.31 $17.39 $20.0078011 $120.78 $114.74 $131.9578011 TC $99.91 $94.91 $109.1578011 26 $20.87 $19.83 $22.8078015 $142.16 $135.05 $155.3178015 TC $111.01 $105.46 $121.2878015 26 $31.14 $29.58 $34.0278016 TC $160.13 $152.12 $174.9478016 26 $38.13 $36.22 $41.6578016 $198.26 $188.35 $216.6078018 $247.49 $235.12 $270.3978018 TC $207.21 $196.85 $226.3878018 26 $40.27 $38.26 $44.0078020 26 $27.86 $26.47 $30.4478020 $78.30 $74.39 $85.5578020 TC $50.44 $47.92 $55.1178070 26 $38.46 $36.54 $42.0278070 TC $136.26 $129.45 $148.8778070 $174.73 $165.99 $190.8978075 $272.31 $258.69 $297.4978075 TC $237.50 $225.63 $259.4778075 26 $34.81 $33.07 $38.0378102 $112.42 $106.80 $122.8278102 TC $87.12 $82.76 $95.1778102 26 $25.29 $24.03 $27.6378103 26 $34.81 $33.07 $38.0378103 $161.63 $153.55 $176.5878103 TC $126.82 $120.48 $138.5578104 26 $37.37 $35.50 $40.8378104 $195.48 $185.71 $213.5778104 TC $158.10 $150.20 $172.7378110 $51.85 $49.26 $56.6578110 TC $42.72 $40.58 $46.6778110 26 $9.13 $8.67 $9.9778111 $96.71 $91.87 $105.6578111 TC $86.11 $81.80 $94.0778111 26 $10.61 $10.08 $11.5978120 26 $10.98 $10.43 $11.9978120 TC $63.23 $60.07 $69.0878120 $74.22 $70.51 $81.0978121 TC $94.86 $90.12 $103.6478121 26 $15.03 $14.28 $16.4278121 $109.88 $104.39 $120.0578122 $161.47 $153.40 $176.4178122 TC $140.60 $133.57 $153.6178122 26 $20.87 $19.83 $22.8078130 $131.51 $124.93 $143.6778130 TC $102.94 $97.79 $112.4678130 26 $28.57 $27.14 $31.21

78135 $227.85 $216.46 $248.9378135 TC $197.80 $187.91 $216.1078135 26 $30.05 $28.55 $32.8378140 $155.72 $147.93 $170.1278140 TC $127.48 $121.11 $139.2878140 26 $28.24 $26.83 $30.8578185 $122.97 $116.82 $134.3478185 TC $104.28 $99.07 $113.9378185 26 $18.68 $17.75 $20.4178190 $277.64 $263.76 $303.3278190 TC $225.05 $213.80 $245.8778190 26 $52.60 $49.97 $57.4778191 $251.58 $239.00 $274.8578191 TC $223.34 $212.17 $244.0078191 26 $28.24 $26.83 $30.8578195 $231.99 $220.39 $253.4578195 TC $175.94 $167.14 $192.2178195 26 $56.05 $53.25 $61.2478201 26 $20.54 $19.51 $22.4478201 $121.12 $115.06 $132.3278201 TC $100.58 $95.55 $109.8878202 $142.24 $135.13 $155.4078202 TC $118.75 $112.81 $129.7378202 26 $23.48 $22.31 $25.6678205 $232.46 $220.84 $253.9778205 TC $199.47 $189.50 $217.9378205 26 $33.00 $31.35 $36.0578206 $310.86 $295.32 $339.6278206 TC $266.16 $252.85 $290.7878206 26 $44.69 $42.46 $48.8378215 TC $115.72 $109.93 $126.4278215 $138.45 $131.53 $151.2678215 26 $22.73 $21.59 $24.8378216 TC $114.70 $108.97 $125.3278216 26 $26.05 $24.75 $28.4678216 $140.75 $133.71 $153.7778220 $145.84 $138.55 $159.3378220 TC $123.11 $116.95 $134.4978220 26 $22.73 $21.59 $24.8378223 26 $39.22 $37.26 $42.8578223 $203.05 $192.90 $221.8478223 TC $163.83 $155.64 $178.9978230 26 $20.54 $19.51 $22.4478230 $111.70 $106.12 $122.0478230 TC $91.16 $86.60 $99.5978231 $130.83 $124.29 $142.9378231 TC $106.63 $101.30 $116.5078231 26 $24.20 $22.99 $26.4478232 $137.68 $130.80 $150.42

78232 TC $116.05 $110.25 $126.7978232 26 $21.63 $20.55 $23.6378258 TC $122.12 $116.01 $133.4178258 $156.92 $149.07 $171.4378258 26 $34.81 $33.07 $38.0378261 TC $157.09 $149.24 $171.6378261 26 $32.24 $30.63 $35.2278261 $189.33 $179.86 $206.8478262 $191.98 $182.38 $209.7478262 TC $160.46 $152.44 $175.3178262 26 $31.52 $29.94 $34.4378264 26 $35.94 $34.14 $39.2678264 $202.46 $192.34 $221.1978264 TC $166.52 $158.19 $181.9278270 26 $9.51 $9.03 $10.3878270 $66.69 $63.36 $72.8678270 TC $57.18 $54.32 $62.4778271 $69.38 $65.91 $75.8078271 TC $59.87 $56.88 $65.4178271 26 $9.51 $9.03 $10.3878272 $91.17 $86.61 $99.6078272 TC $78.71 $74.77 $85.9978272 26 $12.46 $11.84 $13.6278278 TC $196.79 $186.95 $214.9978278 $242.63 $230.50 $265.0878278 26 $45.83 $43.54 $50.0778282 26 $17.59 $16.71 $19.2278290 $179.21 $170.25 $195.7978290 TC $147.69 $140.31 $161.3678290 26 $31.52 $29.94 $34.4378291 $170.55 $162.02 $186.3278291 TC $129.52 $123.04 $141.5078291 26 $41.03 $38.98 $44.8378300 $127.85 $121.46 $139.6878300 TC $98.90 $93.96 $108.0578300 26 $28.95 $27.50 $31.6378305 TC $139.94 $132.94 $152.8878305 26 $38.84 $36.90 $42.4478305 $178.78 $169.84 $195.3278306 TC $160.79 $152.75 $175.6678306 26 $39.94 $37.94 $43.6378306 $200.73 $190.69 $219.2978315 $241.74 $229.65 $264.1078315 TC $194.44 $184.72 $212.4378315 26 $47.31 $44.94 $51.6878320 $247.53 $235.15 $270.4278320 TC $199.13 $189.17 $217.5578320 26 $48.40 $45.98 $52.8878414 26 $21.21 $20.15 $23.17

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

78428 26 $37.96 $36.06 $41.4778428 $140.23 $133.22 $153.2078428 TC $102.27 $97.16 $111.7378445 $108.84 $103.40 $118.9178445 TC $85.78 $81.49 $93.7178445 26 $23.06 $21.91 $25.2078456 $237.27 $225.41 $259.2278456 TC $189.04 $179.59 $206.5378456 26 $48.23 $45.82 $52.6978457 26 $35.56 $33.78 $38.8578457 $143.55 $136.37 $156.8378457 TC $107.98 $102.58 $117.9778458 26 $42.13 $40.02 $46.0278458 $184.75 $175.51 $201.8478458 TC $142.62 $135.49 $155.8178459 $1,372.09 $1,303.49 $1,499.0178459 TC $1,297.09 $1,232.24 $1,417.0878459 26 $71.67 $68.09 $78.3078460 $139.17 $132.21 $152.0478460 TC $98.90 $93.96 $108.0578460 26 $40.27 $38.26 $44.0078461 TC $156.07 $148.27 $170.5178461 26 $57.87 $54.98 $63.2378461 $213.94 $203.24 $233.7378464 $287.39 $273.02 $313.9778464 TC $235.12 $223.36 $256.8678464 26 $52.27 $49.66 $57.1178465 $478.52 $454.59 $522.7878465 TC $408.02 $387.62 $445.7678465 26 $70.50 $66.98 $77.0378466 $137.87 $130.98 $150.6378466 TC $105.29 $100.03 $115.0378466 26 $32.57 $30.94 $35.5878468 TC $145.66 $138.38 $159.1478468 26 $38.72 $36.78 $42.3078468 $184.38 $175.16 $201.4378469 TC $189.72 $180.23 $207.2678469 26 $43.90 $41.71 $47.9778469 $233.62 $221.94 $255.2378472 $242.23 $230.12 $264.6478472 TC $195.77 $185.98 $213.8878472 26 $46.46 $44.14 $50.7678473 $350.74 $333.20 $383.1878473 TC $280.88 $266.84 $306.8778473 26 $69.86 $66.37 $76.3378478 26 $25.46 $24.19 $27.8278478 TC $47.42 $45.05 $51.8178478 $72.88 $69.24 $79.6378480 26 $17.63 $16.75 $19.26

78480 $65.05 $61.80 $71.0778480 TC $47.42 $45.05 $51.8178481 $227.43 $216.06 $248.4778481 TC $179.62 $170.64 $196.2478481 26 $47.81 $45.42 $52.2378483 $335.26 $318.50 $366.2878483 TC $263.38 $250.21 $287.7478483 26 $71.88 $68.29 $78.5378491 TC $1,297.09 $1,232.24 $1,417.0878491 $1,372.09 $1,303.49 $1,499.0178491 26 $73.02 $69.37 $79.7878492 TC $1,556.51 $1,478.68 $1,700.4878492 26 $92.25 $87.64 $100.7978492 $1,646.51 $1,564.18 $1,798.8178494 $293.51 $278.83 $320.6578494 TC $236.15 $224.34 $257.9978494 26 $57.36 $54.49 $62.6678496 26 $24.45 $23.23 $26.7178496 $218.54 $207.61 $238.7578496 TC $194.09 $184.39 $212.0578580 26 $34.47 $32.75 $37.6678580 $166.00 $157.70 $181.3678580 TC $131.53 $124.95 $143.6978584 $153.13 $145.47 $167.2978584 TC $107.30 $101.94 $117.2378584 26 $45.83 $43.54 $50.0778585 $268.57 $255.14 $293.4178585 TC $217.98 $207.08 $238.1478585 26 $50.59 $48.06 $55.2778586 TC $101.93 $96.83 $111.3578586 $120.61 $114.58 $131.7778586 26 $18.68 $17.75 $20.4178587 TC $117.41 $111.54 $128.2778587 26 $22.73 $21.59 $24.8378587 $140.13 $133.12 $153.0978588 $202.98 $192.83 $221.7578588 TC $152.39 $144.77 $166.4978588 26 $50.59 $48.06 $55.2778591 26 $18.68 $17.75 $20.4178591 $127.01 $120.66 $138.7678591 TC $108.32 $102.90 $118.3478593 26 $22.73 $21.59 $24.8378593 $152.57 $144.94 $166.6878593 TC $129.85 $123.36 $141.8678594 $199.50 $189.53 $217.9678594 TC $174.92 $166.17 $191.1078594 26 $24.58 $23.35 $26.8578596 $316.34 $300.52 $345.6078596 TC $258.01 $245.11 $281.88

78596 26 $58.33 $55.41 $63.7278600 TC $133.90 $127.21 $146.2978600 $154.43 $146.71 $168.7278600 26 $20.54 $19.51 $22.4478601 TC $132.87 $126.23 $145.1678601 26 $23.48 $22.31 $25.6678601 $156.36 $148.54 $170.8278605 $152.74 $145.10 $166.8778605 TC $128.16 $121.75 $140.0178605 26 $24.58 $23.35 $26.8578606 26 $29.71 $28.22 $32.4578606 $200.94 $190.89 $219.5278606 TC $171.23 $162.67 $187.0778607 $352.56 $334.93 $385.1778607 TC $295.03 $280.28 $322.3278607 26 $57.53 $54.65 $62.8578608 $1,372.09 $1,303.49 $1,499.0178608 TC $1,297.09 $1,232.24 $1,417.0878608 26 $69.65 $66.17 $76.1078609 26 $69.65 $66.17 $76.1078609 $1,372.09 $1,303.49 $1,499.0178609 TC $1,297.09 $1,232.24 $1,417.0878610 26 $14.27 $13.56 $15.5978610 $91.98 $87.38 $100.4978610 TC $77.71 $73.82 $84.8978615 $165.43 $157.16 $180.7378615 TC $145.65 $138.37 $159.1378615 26 $19.78 $18.79 $21.6178630 $234.37 $222.65 $256.0578630 TC $202.85 $192.71 $221.6278630 26 $31.52 $29.94 $34.4378635 TC $135.24 $128.48 $147.7578635 26 $28.91 $27.46 $31.5878635 $164.16 $155.95 $179.3478645 $184.50 $175.28 $201.5778645 TC $158.45 $150.53 $173.1178645 26 $26.05 $24.75 $28.4678647 $313.61 $297.93 $342.6278647 TC $271.82 $258.23 $296.9678647 26 $41.79 $39.70 $45.6678650 $221.00 $209.95 $241.4478650 TC $192.42 $182.80 $210.2278650 26 $28.57 $27.14 $31.2178660 $115.07 $109.32 $125.7278660 TC $90.15 $85.64 $98.4978660 26 $24.92 $23.67 $27.2278700 $137.94 $131.04 $150.7078700 TC $117.06 $111.21 $127.8978700 26 $20.87 $19.83 $22.80

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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NONPAR CHARGEFEE FEE

New Mexico Disclosure

78701 $159.98 $151.98 $174.7878701 TC $137.25 $130.39 $149.9578701 26 $22.73 $21.59 $24.8378707 $205.82 $195.53 $224.8678707 TC $161.46 $153.39 $176.4078707 26 $44.36 $42.14 $48.4678708 $200.40 $190.38 $218.9478708 TC $144.30 $137.09 $157.6578708 26 $56.10 $53.30 $61.3078709 $252.65 $240.02 $276.0278709 TC $187.38 $178.01 $204.7178709 26 $65.27 $62.01 $71.3178710 $230.57 $219.04 $251.9078710 TC $200.14 $190.13 $218.6578710 26 $30.43 $28.91 $33.2578725 26 $17.93 $17.03 $19.5878725 $84.53 $80.30 $92.3578725 TC $66.60 $63.27 $72.7678730 26 $9.30 $8.84 $10.1778730 $64.80 $61.56 $70.7978730 TC $55.50 $52.73 $60.6478740 26 $26.39 $25.07 $28.8378740 $125.96 $119.66 $137.6178740 TC $99.58 $94.60 $108.7978761 26 $33.00 $31.35 $36.0578761 $156.45 $148.63 $170.9278761 TC $123.45 $117.28 $134.8778800 26 $30.76 $29.22 $33.6078800 $155.22 $147.46 $169.5878800 TC $124.46 $118.24 $135.9878801 $197.78 $187.89 $216.0778801 TC $160.46 $152.44 $175.3178801 26 $37.32 $35.45 $40.7778802 $252.20 $239.59 $275.5378802 TC $212.26 $201.65 $231.9078802 26 $39.94 $37.94 $43.6378803 $344.27 $327.06 $376.1278803 TC $293.35 $278.68 $320.4878803 26 $50.92 $48.37 $55.6378804 $454.25 $431.54 $496.2778804 TC $404.75 $384.51 $442.1978804 26 $49.49 $47.02 $54.0778805 $157.54 $149.66 $172.1178805 TC $123.45 $117.28 $134.8778805 26 $34.09 $32.39 $37.2578806 26 $39.94 $37.94 $43.6378806 $278.09 $264.19 $303.8278806 TC $238.16 $226.25 $260.1978807 26 $50.93 $48.38 $55.64

78807 $338.22 $321.31 $369.5178807 TC $287.29 $272.93 $313.8778811 $2,078.62 $1,974.69 $2,270.8978811 TC $2,003.62 $1,903.44 $2,188.9678811 26 $73.51 $69.83 $80.3078812 $2,078.62 $1,974.69 $2,270.8978812 TC $2,003.62 $1,903.44 $2,188.9678812 26 $91.15 $86.59 $99.5878813 $2,078.62 $1,974.69 $2,270.8978813 TC $2,003.62 $1,903.44 $2,188.9678813 26 $94.09 $89.39 $102.8078814 $2,252.50 $2,139.88 $2,460.8678814 TC $2,128.17 $2,021.76 $2,325.0278814 26 $103.27 $98.11 $112.8378815 $2,252.50 $2,139.88 $2,460.8678815 TC $2,128.17 $2,021.76 $2,325.0278815 26 $113.92 $108.22 $124.4578816 26 $116.87 $111.03 $127.6878816 $2,252.50 $2,139.88 $2,460.8678816 TC $2,128.17 $2,021.76 $2,325.0279005 26 $83.58 $79.40 $91.3179005 $164.64 $156.41 $179.8779005 TC $81.06 $77.01 $88.5679101 $174.32 $165.60 $190.4479101 TC $82.41 $78.29 $90.0379101 26 $91.92 $87.32 $100.4279200 $176.80 $167.96 $193.1579200 TC $83.75 $79.56 $91.4979200 26 $93.05 $88.40 $101.6679300 26 $77.75 $73.86 $84.9479403 TC $130.19 $123.68 $142.2379403 26 $108.16 $102.75 $118.1679403 $238.35 $226.43 $260.3979440 $173.44 $164.77 $189.4979440 TC $80.05 $76.05 $87.4679440 26 $93.39 $88.72 $102.0379445 26 $112.45 $106.83 $122.8580500 $19.91 $18.91 $21.75

# 80500 $17.89 $17.00 $19.5580502 $62.96 $59.81 $68.78

# 80502 $62.63 $59.50 $68.4383020 26 $17.55 $16.67 $19.1783912 26 $16.88 $16.04 $18.4584165 26 $17.21 $16.35 $18.8084166 26 $17.21 $16.35 $18.8084181 26 $17.55 $16.67 $19.1784182 26 $18.22 $17.31 $19.9185060 $21.55 $20.47 $23.5485097 $92.78 $88.14 $101.36

# 85097 $46.33 $44.01 $50.6185390 26 $17.21 $16.35 $18.8085396 $18.22 $17.31 $19.9185576 26 $17.89 $17.00 $19.5586077 $46.34 $44.02 $50.62

# 86077 $45.66 $43.38 $49.8986078 $48.02 $45.62 $52.46

# 86078 $46.00 $43.70 $50.2686079 $47.68 $45.30 $52.10

# 86079 $46.00 $43.70 $50.2686255 26 $17.55 $16.67 $19.1786256 26 $17.55 $16.67 $19.1786320 26 $17.55 $16.67 $19.1786325 26 $17.21 $16.35 $18.8086327 26 $20.79 $19.75 $22.7186334 26 $17.55 $16.67 $19.1786335 26 $17.55 $16.67 $19.1786490 $9.08 $8.63 $9.9286510 $10.09 $9.59 $11.0386580 $8.41 $7.99 $9.1987164 26 $16.88 $16.04 $18.4587207 26 $17.89 $17.00 $19.5588104 $51.58 $49.00 $56.3588104 TC $24.56 $23.33 $26.8388104 26 $27.02 $25.67 $29.5288106 26 $27.02 $25.67 $29.5288106 $67.06 $63.71 $73.2788106 TC $40.04 $38.04 $43.7588107 26 $37.20 $35.34 $40.6488107 $83.30 $79.14 $91.0188107 TC $46.10 $43.80 $50.3788108 $63.02 $59.87 $68.8588108 TC $36.00 $34.20 $39.3388108 26 $27.02 $25.67 $29.5288112 $103.76 $98.57 $113.3688112 TC $47.44 $45.07 $51.8388112 26 $56.32 $53.50 $61.5388125 26 $12.42 $11.80 $13.5788125 $18.47 $17.55 $20.1888125 TC $6.05 $5.75 $6.6188141 $22.14 $21.03 $24.1888160 TC $22.88 $21.74 $25.0088160 26 $24.11 $22.90 $26.3488160 $46.99 $44.64 $51.3488161 $51.70 $49.12 $56.4988161 TC $27.25 $25.89 $29.7788161 26 $24.45 $23.23 $26.7188162 26 $36.53 $34.70 $39.9188162 $62.77 $59.63 $68.57

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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NONPAR CHARGEFEE FEE

New Mexico Disclosure

88162 TC $26.24 $24.93 $28.6788172 $47.37 $45.00 $51.7588172 TC $18.17 $17.26 $19.8588172 26 $29.21 $27.75 $31.9188173 $123.07 $116.92 $134.4688173 TC $55.86 $53.07 $61.0388173 26 $67.21 $63.85 $73.4388182 $94.78 $90.04 $103.5588182 TC $58.21 $55.30 $63.6088182 26 $36.57 $34.74 $39.9588184 $54.51 $51.78 $59.5588185 $29.27 $27.81 $31.9888187 $61.38 $58.31 $67.0688188 $76.11 $72.30 $83.1588189 $99.39 $94.42 $108.5888291 $25.21 $23.95 $27.5488300 TC $15.81 $15.02 $17.2788300 26 $4.00 $3.80 $4.3788300 $19.81 $18.82 $21.6488302 $42.57 $40.44 $46.5188302 TC $35.67 $33.89 $38.9788302 26 $6.90 $6.56 $7.5488304 $54.68 $51.95 $59.7488304 TC $44.08 $41.88 $48.1688304 26 $10.61 $10.08 $11.5988305 $94.02 $89.32 $102.7288305 TC $57.53 $54.65 $62.8588305 26 $36.49 $34.67 $39.8788307 $175.31 $166.54 $191.5288307 TC $97.91 $93.01 $106.9688307 26 $77.40 $73.53 $84.5688309 $263.72 $250.53 $288.1188309 TC $133.92 $127.22 $146.3088309 26 $129.80 $123.31 $141.8188311 TC $5.04 $4.79 $5.5188311 $16.74 $15.90 $18.2988311 26 $11.70 $11.12 $12.7988312 TC $52.50 $49.88 $57.3688312 26 $26.30 $24.99 $28.7488312 $78.80 $74.86 $86.0988313 $56.79 $53.95 $62.0488313 TC $45.09 $42.84 $49.2788313 26 $11.70 $11.12 $12.7988314 $85.15 $80.89 $93.0288314 TC $63.26 $60.10 $69.1288314 26 $21.88 $20.79 $23.9188318 $82.03 $77.93 $89.6288318 TC $61.25 $58.19 $66.9288318 26 $20.79 $19.75 $22.71

88319 $132.60 $125.97 $144.8788319 TC $107.01 $101.66 $116.9188319 26 $25.59 $24.31 $27.9688321 $83.63 $79.45 $91.37

# 88321 $75.55 $71.77 $82.5488323 $128.13 $121.72 $139.9888323 TC $45.76 $43.47 $49.9988323 26 $82.37 $78.25 $89.9988325 $180.49 $171.47 $197.19

# 88325 $116.88 $111.04 $127.7088329 $45.62 $43.34 $49.84

# 88329 $32.49 $30.87 $35.5088331 $81.58 $77.50 $89.1388331 TC $23.54 $22.36 $25.7188331 26 $58.04 $55.14 $63.4188332 $36.90 $35.06 $40.3288332 TC $8.41 $7.99 $9.1988332 26 $28.49 $27.07 $31.1388333 $82.30 $78.19 $89.9288333 TC $23.54 $22.36 $25.7188333 26 $58.75 $55.81 $64.1888334 $48.22 $45.81 $52.6888334 TC $14.13 $13.42 $15.4388334 26 $34.09 $32.39 $37.2588342 26 $40.91 $38.86 $44.6988342 $84.31 $80.09 $92.1088342 TC $43.41 $41.24 $47.4388346 26 $41.29 $39.23 $45.1188346 $87.05 $82.70 $95.1188346 TC $45.76 $43.47 $49.9988347 $73.92 $70.22 $80.7588347 TC $33.31 $31.64 $36.3988347 26 $40.61 $38.58 $44.3788348 $442.21 $420.10 $483.1288348 TC $369.15 $350.69 $403.2988348 26 $73.06 $69.41 $79.8288349 26 $36.87 $35.03 $40.2888349 $193.00 $183.35 $210.8588349 TC $156.13 $148.32 $170.5788355 26 $88.46 $84.04 $96.6588355 $316.61 $300.78 $345.9088355 TC $228.15 $216.74 $249.2588356 $270.62 $257.09 $295.6588356 TC $125.17 $118.91 $136.7588356 26 $145.45 $138.18 $158.9188358 $68.51 $65.08 $74.8488358 TC $21.52 $20.44 $23.5188358 26 $46.99 $44.64 $51.3488360 26 $53.65 $50.97 $58.62

88360 TC $49.46 $46.99 $54.0488360 $103.12 $97.96 $112.6588361 TC $86.80 $82.46 $94.8388361 26 $57.98 $55.08 $63.3488361 $144.78 $137.54 $158.1788362 $241.45 $229.38 $263.7988362 TC $136.28 $129.47 $148.8988362 26 $105.17 $99.91 $114.9088365 $120.67 $114.64 $131.8488365 TC $63.93 $60.73 $69.8488365 26 $56.74 $53.90 $61.9988367 $193.39 $183.72 $211.2888367 TC $131.56 $124.98 $143.7388367 26 $61.82 $58.73 $67.5488368 $151.37 $143.80 $165.3788368 TC $84.79 $80.55 $92.6388368 26 $66.58 $63.25 $72.7488371 26 $16.88 $16.04 $18.4588372 26 $17.89 $17.00 $19.5588385 $354.68 $336.95 $387.4988385 TC $283.34 $269.17 $309.5588385 26 $71.34 $67.77 $77.9488386 26 $89.94 $85.44 $98.2688386 TC $276.94 $263.09 $302.5588386 $366.88 $348.54 $400.8289049 $170.57 $162.04 $186.35

# 89049 $58.50 $55.58 $63.9289060 26 $17.89 $17.00 $19.5589100 $141.94 $134.84 $155.07

# 89100 $31.90 $30.31 $34.8689105 $137.53 $130.65 $150.25

# 89105 $25.80 $24.51 $28.1989130 $117.46 $111.59 $128.33

# 89130 $22.56 $21.43 $24.6489132 $100.33 $95.31 $109.61

# 89132 $10.81 $10.27 $11.8189135 $150.40 $142.88 $164.31

# 89135 $40.36 $38.34 $44.0989136 $110.18 $104.67 $120.37

# 89136 $12.58 $11.95 $13.7489140 $142.92 $135.77 $156.14

# 89140 $44.65 $42.42 $48.7889141 $145.23 $137.97 $158.67

# 89141 $41.24 $39.18 $45.0689220 $14.46 $13.74 $15.8089230 $4.03 $3.83 $4.4090465 $17.80 $16.91 $19.4590466 $9.64 $9.16 $10.53

# 90466 $8.96 $8.51 $9.79

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

90467 $11.74 $11.15 $12.82# 90467 $9.05 $8.60 $9.89

90468 $8.96 $8.51 $9.79# 90468 $6.94 $6.59 $7.58

90471 $17.80 $16.91 $19.4590472 $9.64 $9.16 $10.53

# 90472 $8.96 $8.51 $9.7990473 $12.08 $11.48 $13.20

# 90473 $8.04 $7.64 $8.7990474 $8.29 $7.88 $9.06

# 90474 $6.94 $6.59 $7.5890760 $55.13 $52.37 $60.2390761 $17.15 $16.29 $18.7390765 $67.42 $64.05 $73.6690766 $22.20 $21.09 $24.2590767 $36.05 $34.25 $39.3990768 $20.82 $19.78 $22.7590772 $17.80 $16.91 $19.4590773 $16.78 $15.94 $18.3390774 $51.48 $48.91 $56.2590775 $23.59 $22.41 $25.7790801 $139.57 $132.59 $152.48

# 90801 $126.11 $119.80 $137.7790802 $148.11 $140.70 $161.81

# 90802 $135.32 $128.55 $147.8390804 $59.47 $56.50 $64.98

# 90804 $53.75 $51.06 $58.7290805 $65.45 $62.18 $71.51

# 90805 $60.40 $57.38 $65.9990806 $86.83 $82.49 $94.86

# 90806 $82.46 $78.34 $90.0990807 $94.20 $89.49 $102.91

# 90807 $89.49 $85.02 $97.7790808 $128.76 $122.32 $140.67

# 90808 $124.05 $117.85 $135.5390809 $135.41 $128.64 $147.94

# 90809 $130.36 $123.84 $142.4290810 $63.60 $60.42 $69.48

# 90810 $59.22 $56.26 $64.7090811 $72.27 $68.66 $78.96

# 90811 $65.54 $62.26 $71.6090812 $93.65 $88.97 $102.32

# 90812 $87.59 $83.21 $95.6990813 $101.02 $95.97 $110.37

# 90813 $94.62 $89.89 $103.3790814 $135.24 $128.48 $147.75

# 90814 $130.19 $123.68 $142.2390815 $141.55 $134.47 $154.64

# 90815 $135.16 $128.40 $147.66

90816 $57.92 $55.02 $63.2790817 $63.94 $60.74 $69.8590818 $86.96 $82.61 $95.0090819 $91.93 $87.33 $100.4390821 $129.26 $122.80 $141.2290822 $133.89 $127.20 $146.2890823 $62.38 $59.26 $68.1590824 $68.73 $65.29 $75.0890826 $92.47 $87.85 $101.0390827 $96.39 $91.57 $105.3190828 $134.02 $127.32 $146.4290829 $138.36 $131.44 $151.1690845 $80.19 $76.18 $87.61

# 90845 $78.84 $74.90 $86.1490846 $84.73 $80.49 $92.56

# 90846 $84.06 $79.86 $91.8490847 $104.01 $98.81 $113.63

# 90847 $100.30 $95.29 $109.5890849 $30.18 $28.67 $32.97

# 90849 $28.49 $27.07 $31.1390853 $29.17 $27.71 $31.87

# 90853 $27.82 $26.43 $30.3990857 $32.37 $30.75 $35.36

# 90857 $30.01 $28.51 $32.7990862 $48.36 $45.94 $52.83

# 90862 $43.31 $41.14 $47.3190865 $145.06 $137.81 $158.48

# 90865 $129.25 $122.79 $141.2190870 $130.33 $123.81 $142.38

# 90870 $83.55 $79.37 $91.2890880 $107.29 $101.93 $117.22

# 90880 $97.19 $92.33 $106.1890901 $35.22 $33.46 $38.48

# 90901 $19.06 $18.11 $20.8390911 $83.13 $78.97 $90.82

# 90911 $42.75 $40.61 $46.7090935 $64.56 $61.33 $70.5390937 $105.64 $100.36 $115.4190945 $67.13 $63.77 $73.3490947 $107.49 $102.12 $117.4490997 $85.40 $81.13 $93.3091000 $53.27 $50.61 $58.2091000 TC $18.84 $17.90 $20.5991000 26 $34.43 $32.71 $37.6291010 TC $128.20 $121.79 $140.0691010 26 $60.26 $57.25 $65.8491010 $188.46 $179.04 $205.9091011 TC $159.16 $151.20 $173.8891011 26 $73.01 $69.36 $79.76

91011 $232.18 $220.57 $253.6691012 26 $70.49 $66.97 $77.0291012 $245.47 $233.20 $268.1891012 TC $174.97 $166.22 $191.1591020 $207.73 $197.34 $226.9491020 TC $138.63 $131.70 $151.4691020 26 $69.10 $65.65 $75.5091022 26 $69.77 $66.28 $76.2291022 $190.91 $181.36 $208.5691022 TC $121.13 $115.07 $132.3391030 26 $44.19 $41.98 $48.2891030 $118.89 $112.95 $129.8991030 TC $74.70 $70.97 $81.6291034 $203.89 $193.70 $222.7691034 TC $156.80 $148.96 $171.3091034 26 $47.09 $44.74 $51.4591035 $425.69 $404.41 $465.0791035 TC $349.30 $331.84 $381.6291035 26 $76.39 $72.57 $83.4691037 26 $47.09 $44.74 $51.4591037 TC $92.19 $87.58 $100.7291037 $139.28 $132.32 $152.1791038 $120.94 $114.89 $132.1291038 TC $67.29 $63.93 $73.5291038 26 $53.65 $50.97 $58.6291040 $396.05 $376.25 $432.6991040 TC $349.30 $331.84 $381.6291040 26 $46.75 $44.41 $51.0791052 TC $77.40 $73.53 $84.5691052 26 $38.34 $36.42 $41.8891052 $115.74 $109.95 $126.4491055 TC $86.15 $81.84 $94.1291055 26 $42.97 $40.82 $46.9491055 $129.11 $122.65 $141.0591065 $55.61 $52.83 $60.7591065 TC $46.10 $43.80 $50.3791065 26 $9.51 $9.03 $10.3891100 $127.60 $121.22 $139.40

# 91100 $49.19 $46.73 $53.7491105 $81.15 $77.09 $88.65

# 91105 $16.54 $15.71 $18.0791110 $861.89 $818.80 $941.6291110 TC $688.18 $653.77 $751.8491110 26 $173.70 $165.02 $189.7791111 $663.40 $630.23 $724.7691111 TC $612.81 $582.17 $669.5091111 26 $50.59 $48.06 $55.2791120 26 $46.41 $44.09 $50.7091120 $389.66 $370.18 $425.71

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

91120 TC $343.25 $326.09 $375.0091122 26 $84.11 $79.90 $91.8991122 $227.45 $216.08 $248.4991122 TC $143.34 $136.17 $156.6091132 26 $25.21 $23.95 $27.5491133 26 $31.77 $30.18 $34.7192002 $63.25 $60.09 $69.10

# 92002 $41.71 $39.62 $45.5692004 $114.38 $108.66 $124.96

# 92004 $80.05 $76.05 $87.4692012 $57.40 $54.53 $62.71

# 92012 $32.83 $31.19 $35.8792014 $85.30 $81.04 $93.20

# 92014 $53.66 $50.98 $58.6392018 $122.60 $116.47 $133.9492019 $63.56 $60.38 $69.4492020 $23.61 $22.43 $25.79

# 92020 $17.89 $17.00 $19.5592025 26 $16.12 $15.31 $17.6192025 $27.22 $25.86 $29.7492025 TC $11.10 $10.55 $12.1392060 26 $33.59 $31.91 $36.7092060 TC $16.15 $15.34 $17.6492060 $49.74 $47.25 $54.3492065 $34.04 $32.34 $37.1992065 TC $16.49 $15.67 $18.0292065 26 $17.55 $16.67 $19.1792070 $59.54 $56.56 $65.04

# 92070 $34.64 $32.91 $37.8592081 $44.76 $42.52 $48.9092081 TC $27.59 $26.21 $30.1492081 26 $17.17 $16.31 $18.7692082 $58.23 $55.32 $63.6292082 TC $36.68 $34.85 $40.0892082 26 $21.55 $20.47 $23.5492083 $66.85 $63.51 $73.0492083 TC $42.40 $40.28 $46.3292083 26 $24.45 $23.23 $26.7192100 $76.88 $73.04 $84.00

# 92100 $43.90 $41.71 $47.9792120 $63.67 $60.49 $69.56

# 92120 $38.76 $36.82 $42.3492130 $70.73 $67.19 $77.27

# 92130 $40.11 $38.10 $43.8292135 26 $16.79 $15.95 $18.3492135 TC $22.21 $21.10 $24.2792135 $39.00 $37.05 $42.6192136 $75.08 $71.33 $82.0392136 TC $48.44 $46.02 $52.92

92136 26 $26.64 $25.31 $29.1192140 $50.03 $47.53 $54.66

# 92140 $24.12 $22.91 $26.3592225 $20.96 $19.91 $22.90

# 92225 $18.27 $17.36 $19.9692226 $19.11 $18.15 $20.87

# 92226 $16.41 $15.59 $17.9392230 $65.89 $62.60 $71.99

# 92230 $27.86 $26.47 $30.4492235 $115.81 $110.02 $126.5292235 TC $75.36 $71.59 $82.3392235 26 $40.45 $38.43 $44.1992240 $232.34 $220.72 $253.8392240 TC $177.67 $168.79 $194.1192240 26 $54.67 $51.94 $59.7392250 26 $21.55 $20.47 $23.5492250 $65.63 $62.35 $71.7092250 TC $44.08 $41.88 $48.1692260 $15.57 $14.79 $17.01

# 92260 $10.18 $9.67 $11.1292265 $75.77 $71.98 $82.7892265 TC $37.69 $35.81 $41.1892265 26 $38.09 $36.19 $41.6292270 $79.81 $75.82 $87.1992270 TC $40.71 $38.67 $44.4792270 26 $39.10 $37.15 $42.7292275 26 $49.62 $47.14 $54.2192275 $106.15 $100.84 $115.9792275 TC $56.53 $53.70 $61.7692283 $36.30 $34.49 $39.6692283 TC $27.93 $26.53 $30.5192283 26 $8.37 $7.95 $9.1492284 26 $11.36 $10.79 $12.4192284 $66.89 $63.55 $73.0892284 TC $55.52 $52.74 $60.6592285 26 $10.18 $9.67 $11.1292285 $39.46 $37.49 $43.1192285 TC $29.28 $27.82 $31.9992286 $118.93 $112.98 $129.9392286 TC $86.48 $82.16 $94.4892286 26 $32.45 $30.83 $35.4592287 $105.06 $99.81 $114.78

# 92287 $38.76 $36.82 $42.3492311 $76.13 $72.32 $83.17

# 92311 $49.54 $47.06 $54.1292312 $83.87 $79.68 $91.63

# 92312 $59.64 $56.66 $65.1692313 $71.50 $67.93 $78.12

# 92313 $42.22 $40.11 $46.13

92315 $48.14 $45.73 $52.59# 92315 $20.88 $19.84 $22.82

92316 $60.80 $57.76 $66.42# 92316 $33.21 $31.55 $36.28

92317 $51.50 $48.93 $56.27# 92317 $20.54 $19.51 $22.44

92325 $17.50 $16.63 $19.1292326 $49.45 $46.98 $54.0392502 $87.87 $83.48 $96.0092504 $23.56 $22.38 $25.74

# 92504 $9.09 $8.64 $9.9492506 $123.06 $116.91 $134.45

# 92506 $42.30 $40.19 $46.2292507 $56.51 $53.68 $61.73

# 92507 $25.55 $24.27 $27.9192508 $26.21 $24.90 $28.64

# 92508 $12.75 $12.11 $13.9392511 $137.83 $130.94 $150.58

# 92511 $54.71 $51.97 $59.7792512 $55.92 $53.12 $61.09

# 92512 $25.29 $24.03 $27.6392516 $55.16 $52.40 $60.26

# 92516 $21.84 $20.75 $23.8692520 $46.58 $44.25 $50.89

# 92520 $38.17 $36.26 $41.7092526 $74.76 $71.02 $81.67

# 92526 $25.63 $24.35 $28.0092541 $50.31 $47.79 $54.9692541 TC $30.28 $28.77 $33.0992541 26 $20.03 $19.03 $21.8892542 $51.41 $48.84 $56.1792542 TC $34.99 $33.24 $38.2392542 26 $16.41 $15.59 $17.9392543 $23.93 $22.73 $26.1492543 TC $18.51 $17.58 $20.2292543 26 $5.43 $5.16 $5.9392544 TC $28.26 $26.85 $30.8892544 $41.01 $38.96 $44.8092544 26 $12.75 $12.11 $13.9392545 TC $25.91 $24.61 $28.3092545 26 $11.66 $11.08 $12.7492545 $37.56 $35.68 $41.0392546 26 $14.23 $13.52 $15.5592546 $76.14 $72.33 $83.1892546 TC $61.92 $58.82 $67.6492547 $5.03 $4.78 $5.5092548 $92.73 $88.09 $101.3092548 TC $67.27 $63.91 $73.5092548 26 $25.46 $24.19 $27.82

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

92552 $17.15 $16.29 $18.7392553 $24.55 $23.32 $26.8292555 $14.12 $13.41 $15.4292556 $20.85 $19.81 $22.7892557 $44.72 $42.48 $48.8592561 $25.89 $24.60 $28.2992562 $17.49 $16.62 $19.1192563 $15.13 $14.37 $16.5392564 $17.15 $16.29 $18.7392565 $13.45 $12.78 $14.7092567 $19.16 $18.20 $20.9392568 $12.10 $11.50 $13.2392569 $13.11 $12.45 $14.3292571 $14.46 $13.74 $15.8092572 $7.74 $7.35 $8.4592575 $17.49 $16.62 $19.1192576 $17.48 $16.61 $19.1092577 $22.53 $21.40 $24.6192579 $27.58 $26.20 $30.1392582 $29.60 $28.12 $32.3492583 $30.94 $29.39 $33.8092584 $79.02 $75.07 $86.3392585 $90.70 $86.17 $99.1092585 TC $66.25 $62.94 $72.3892585 26 $24.45 $23.23 $26.7192586 $63.23 $60.07 $69.0892587 TC $41.70 $39.62 $45.5692587 26 $6.90 $6.56 $7.5492587 $48.60 $46.17 $53.1092588 $66.60 $63.27 $72.7692588 TC $49.09 $46.64 $53.6492588 26 $17.51 $16.63 $19.1292596 $24.89 $23.65 $27.2092597 $87.06 $82.71 $95.12

# 92597 $43.64 $41.46 $47.6892601 $131.56 $124.98 $143.7392602 $90.51 $85.98 $98.8892603 $83.10 $78.95 $90.7992604 $54.16 $51.45 $59.1792607 $115.41 $109.64 $126.0992608 $22.87 $21.73 $24.9992609 $60.90 $57.86 $66.5492610 $102.95 $97.80 $112.4792611 $104.97 $99.72 $114.6892612 $136.75 $129.91 $149.40

# 92612 $64.39 $61.17 $70.3592613 $38.04 $36.14 $41.56

# 92613 $37.70 $35.82 $41.1992614 $126.65 $120.32 $138.37

# 92614 $64.39 $61.17 $70.3592615 $33.70 $32.02 $36.8292616 $176.09 $167.29 $192.38

# 92616 $95.66 $90.88 $104.5192617 $41.70 $39.62 $45.5692620 $46.42 $44.10 $50.7292621 $11.76 $11.17 $12.8592625 $45.75 $43.46 $49.9892626 $73.01 $69.36 $79.7692627 $18.17 $17.26 $19.8592640 $47.45 $45.08 $51.8492950 $271.83 $258.24 $296.98

# 92950 $169.87 $161.38 $185.5992953 $10.98 $10.43 $11.9992960 $275.08 $261.33 $300.53

# 92960 $120.95 $114.90 $132.1492961 $239.89 $227.90 $262.0992970 $165.48 $157.21 $180.7992971 $92.88 $88.24 $101.4892973 $167.26 $158.90 $182.7492974 $153.41 $145.74 $167.6092975 $367.38 $349.01 $401.3692977 $232.74 $221.10 $254.2792978 26 $89.64 $85.16 $97.9392979 26 $72.13 $68.52 $78.8092980 $763.32 $725.15 $833.9292981 $211.98 $201.38 $231.5992982 $566.27 $537.96 $618.6592984 $151.27 $143.71 $165.2792986 $1,256.33 $1,193.51 $1,372.5492987 $1,298.99 $1,234.04 $1,419.1592990 $1,000.00 $950.00 $1,092.5092995 $622.99 $591.84 $680.6292996 $161.83 $153.74 $176.8092997 $587.41 $558.04 $641.7592998 $292.69 $278.06 $319.7793000 $22.50 $21.38 $24.5993005 $14.46 $13.74 $15.8093010 $8.04 $7.64 $8.7993012 $192.78 $183.14 $210.6193014 $25.21 $23.95 $27.5493015 $95.68 $90.90 $104.5493016 $22.22 $21.11 $24.2893017 $58.86 $55.92 $64.3193018 $14.60 $13.87 $15.9593024 TC $46.42 $44.10 $50.7293024 26 $57.62 $54.74 $62.9593024 $104.03 $98.83 $113.6593025 $254.53 $241.80 $278.07

93025 TC $217.70 $206.82 $237.8493025 26 $36.82 $34.98 $40.2393040 $12.70 $12.07 $13.8893041 $5.38 $5.11 $5.8893042 $7.32 $6.95 $7.9993224 $136.53 $129.70 $149.1693225 $43.05 $40.90 $47.0493226 $67.94 $64.54 $74.2293227 $25.55 $24.27 $27.9193230 $143.93 $136.73 $157.2493231 $49.77 $47.28 $54.3793232 $68.95 $65.50 $75.3393233 $25.21 $23.95 $27.5493237 $21.88 $20.79 $23.9193268 $263.39 $250.22 $287.7593270 $36.32 $34.50 $39.6893271 $201.86 $191.77 $220.5493272 $25.21 $23.95 $27.5493278 $49.02 $46.57 $53.5693278 TC $36.98 $35.13 $40.4093278 26 $12.04 $11.44 $13.1693303 $201.75 $191.66 $220.4193303 TC $138.92 $131.97 $151.7793303 26 $62.84 $59.70 $68.6693304 TC $77.36 $73.49 $84.5193304 26 $35.82 $34.03 $39.1393304 $113.18 $107.52 $123.6593307 TC $132.86 $126.22 $145.1593307 26 $45.24 $42.98 $49.4393307 $178.10 $169.20 $194.5893308 $99.25 $94.29 $108.4393308 TC $72.99 $69.34 $79.7493308 26 $26.26 $24.95 $28.6993312 $266.07 $252.77 $290.6993312 TC $159.76 $151.77 $174.5493312 26 $106.31 $100.99 $116.1493313 $40.61 $38.58 $44.3793314 $221.38 $210.31 $241.8693314 26 $60.61 $57.58 $66.2293314 TC $160.77 $152.73 $175.6493315 26 $134.76 $128.02 $147.2293316 $42.29 $40.18 $46.2193317 26 $88.42 $84.00 $96.6093318 26 $99.56 $94.58 $108.7793320 $78.47 $74.55 $85.7393320 TC $59.87 $56.88 $65.4193320 26 $18.60 $17.67 $20.3293321 TC $35.31 $33.54 $38.5793321 26 $7.62 $7.24 $8.33

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

93321 $42.93 $40.78 $46.9093325 TC $85.41 $81.14 $93.3193325 26 $3.62 $3.44 $3.9693325 $89.03 $84.58 $97.2793350 $158.38 $150.46 $173.0393350 TC $85.10 $80.85 $92.9893350 26 $73.27 $69.61 $80.0593501 26 $152.82 $145.18 $166.9693503 $127.16 $120.80 $138.9293505 26 $221.20 $210.14 $241.6693508 26 $220.48 $209.46 $240.8893510 26 $232.14 $220.53 $253.6193511 26 $266.72 $253.38 $291.3993514 26 $361.90 $343.81 $395.3893524 26 $364.55 $346.32 $398.2793526 26 $316.50 $300.68 $345.7893527 26 $382.31 $363.19 $417.6793528 26 $468.27 $444.86 $511.5993529 26 $253.76 $241.07 $277.2393530 26 $218.30 $207.39 $238.5093531 26 $425.73 $404.44 $465.1193532 26 $505.39 $480.12 $552.1493533 26 $340.40 $323.38 $371.8993539 $20.03 $19.03 $21.8893540 $21.51 $20.43 $23.4993541 $14.23 $13.52 $15.5593542 $14.23 $13.52 $15.5593543 $14.23 $13.52 $15.5593544 $12.37 $11.75 $13.5193545 $20.03 $19.03 $21.8893555 26 $40.44 $38.42 $44.1893556 26 $41.54 $39.46 $45.3893561 26 $23.11 $21.95 $25.2493562 26 $7.32 $6.95 $7.9993571 26 $88.97 $84.52 $97.2093572 26 $69.45 $65.98 $75.8893580 $922.33 $876.21 $1,007.6493581 $1,238.49 $1,176.57 $1,353.0693600 26 $108.01 $102.61 $118.0093602 26 $108.00 $102.60 $117.9993603 26 $108.00 $102.60 $117.9993609 26 $254.19 $241.48 $277.7093610 26 $153.15 $145.49 $167.3193612 26 $153.15 $145.49 $167.3193613 $356.69 $338.86 $389.6993615 26 $45.83 $43.54 $50.0793616 26 $68.25 $64.84 $74.5793618 26 $216.69 $205.86 $236.7493619 26 $379.41 $360.44 $414.51

93620 26 $596.86 $567.02 $652.0793620 TC $305.30 $290.04 $333.5593620 $917.58 $871.70 $1,002.4693621 26 $106.92 $101.57 $116.8193622 26 $157.83 $149.94 $172.4393623 26 $144.74 $137.50 $158.1393631 26 $384.41 $365.19 $419.9793640 26 $178.24 $169.33 $194.7393641 26 $300.77 $285.73 $328.5993642 26 $249.78 $237.29 $272.8893642 $484.89 $460.65 $529.7593642 TC $235.11 $223.35 $256.8593650 $544.60 $517.37 $594.9893651 $825.21 $783.95 $901.5493652 $897.54 $852.66 $980.5693660 $153.92 $146.22 $168.1593660 TC $60.23 $57.22 $65.8093660 26 $93.69 $89.01 $102.3693662 26 $139.56 $132.58 $152.4793701 $36.98 $35.13 $40.4093701 TC $28.60 $27.17 $31.2593701 26 $8.37 $7.95 $9.1493720 $37.30 $35.44 $40.7693721 $29.60 $28.12 $32.3493722 $7.70 $7.32 $8.4293724 $357.40 $339.53 $390.4693724 TC $115.69 $109.91 $126.4093724 26 $241.71 $229.62 $264.0693727 $28.91 $27.46 $31.5893731 $40.38 $38.36 $44.1193731 TC $18.50 $17.58 $20.2293731 26 $21.89 $20.80 $23.9293732 $65.42 $62.15 $71.4793732 TC $19.84 $18.85 $21.6893732 26 $45.58 $43.30 $49.8093733 $35.95 $34.15 $39.2793733 TC $27.58 $26.20 $30.1393733 26 $8.37 $7.95 $9.1493734 $32.39 $30.77 $35.3993734 TC $13.79 $13.10 $15.0793734 26 $18.60 $17.67 $20.3293735 TC $17.15 $16.29 $18.7393735 $53.64 $50.96 $58.6093735 26 $36.49 $34.67 $39.8793736 $32.16 $30.55 $35.1393736 TC $24.89 $23.65 $27.2093736 26 $7.28 $6.92 $7.9693741 $62.94 $59.79 $68.7693741 TC $23.21 $22.05 $25.36

93741 26 $39.73 $37.74 $43.4093742 $69.42 $65.95 $75.8493742 TC $23.88 $22.69 $26.0993742 26 $45.54 $43.26 $49.7593743 $76.28 $72.47 $83.3493743 TC $25.23 $23.97 $27.5793743 26 $51.05 $48.50 $55.7893744 26 $58.67 $55.74 $64.1093744 $82.89 $78.75 $90.5693744 TC $24.22 $23.01 $26.4693784 $65.71 $62.42 $71.7893786 $30.62 $29.09 $33.4593788 $17.50 $16.63 $19.1293790 $17.59 $16.71 $19.2293797 $16.83 $15.99 $18.39

# 93797 $9.09 $8.64 $9.9493798 $25.29 $24.03 $27.63

# 93798 $13.85 $13.16 $15.1393875 $91.68 $87.10 $100.1793875 TC $81.07 $77.02 $88.5793875 26 $10.61 $10.08 $11.5993880 $224.28 $213.07 $245.0393880 26 $28.53 $27.10 $31.1793880 TC $195.75 $185.96 $213.8593882 $144.47 $137.25 $157.8493882 TC $125.12 $118.86 $136.6993882 26 $19.35 $18.38 $21.1493886 $275.05 $261.30 $300.5093886 TC $229.06 $217.61 $250.2593886 26 $45.99 $43.69 $50.2493888 $178.62 $169.69 $195.1493888 TC $148.33 $140.91 $162.0593888 26 $30.29 $28.78 $33.1093890 $224.11 $212.90 $244.8493890 TC $175.21 $166.45 $191.4293890 26 $48.90 $46.46 $53.4393892 $239.81 $227.82 $261.9993892 TC $184.30 $175.09 $201.3593892 26 $55.51 $52.73 $60.6493893 $233.75 $222.06 $255.3793893 TC $178.24 $169.33 $194.7393893 26 $55.51 $52.73 $60.6493922 26 $11.70 $11.12 $12.7993922 $106.90 $101.56 $116.7993922 TC $95.20 $90.44 $104.0193923 26 $21.54 $20.46 $23.5393923 TC $142.96 $135.81 $156.1893923 $164.50 $156.28 $179.7293924 $197.01 $187.16 $215.23

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

93924 TC $172.56 $163.93 $188.5293924 26 $24.44 $23.22 $26.7093925 $269.97 $256.47 $294.9493925 TC $242.20 $230.09 $264.6093925 26 $27.77 $26.38 $30.3493926 26 $18.97 $18.02 $20.7293926 $167.31 $158.94 $182.7893926 TC $148.34 $140.92 $162.0693930 TC $193.39 $183.72 $211.2893930 26 $22.26 $21.15 $24.3293930 $215.65 $204.87 $235.6093931 $142.11 $135.00 $155.2593931 TC $127.14 $120.78 $138.9093931 26 $14.98 $14.23 $16.3693965 26 $16.45 $15.63 $17.9793965 $111.66 $106.08 $121.9993965 TC $95.20 $90.44 $104.0193970 26 $32.52 $30.89 $35.5293970 $221.53 $210.45 $242.0293970 TC $189.01 $179.56 $206.4993971 $148.67 $141.24 $162.4393971 TC $127.46 $121.09 $139.2593971 26 $21.21 $20.15 $23.1793975 $341.89 $324.80 $373.5293975 TC $255.97 $243.17 $279.6593975 26 $85.92 $81.62 $93.8693976 TC $142.60 $135.47 $155.7993976 $198.70 $188.77 $217.0993976 26 $56.10 $53.30 $61.3093978 TC $168.15 $159.74 $183.7093978 26 $31.39 $29.82 $34.2993978 $199.54 $189.56 $217.9993979 $140.60 $133.57 $153.6193979 TC $119.40 $113.43 $130.4493979 26 $21.21 $20.15 $23.1793980 26 $59.58 $56.60 $65.0993980 $158.08 $150.18 $172.7193980 TC $98.50 $93.58 $107.6293981 26 $20.87 $19.83 $22.8093981 $122.08 $115.98 $133.3893981 TC $101.20 $96.14 $110.5693990 $161.04 $152.99 $175.9493990 TC $149.01 $141.56 $162.7993990 26 $12.03 $11.43 $13.1494002 $82.28 $78.17 $89.9094003 $59.72 $56.73 $65.2494004 $43.52 $41.34 $47.5494010 TC $22.20 $21.09 $24.2594010 $29.91 $28.41 $32.67

94010 26 $7.70 $7.32 $8.4294014 $44.73 $42.49 $48.8694015 $20.86 $19.82 $22.7994016 $23.86 $22.67 $26.0794060 $50.97 $48.42 $55.6894060 TC $37.00 $35.15 $40.4294060 26 $13.97 $13.27 $15.2694070 26 $27.19 $25.83 $29.7094070 $53.74 $51.05 $58.7194070 TC $26.56 $25.23 $29.0194200 26 $5.13 $4.87 $5.6094200 $19.93 $18.93 $21.7794200 TC $14.80 $14.06 $16.1794240 $34.27 $32.56 $37.4494240 TC $22.53 $21.40 $24.6194240 26 $11.74 $11.15 $12.8294250 $24.99 $23.74 $27.3094250 TC $19.85 $18.86 $21.6994250 26 $5.13 $4.87 $5.6094260 TC $21.19 $20.13 $23.1594260 $27.42 $26.05 $29.9694260 26 $6.23 $5.92 $6.8194350 TC $23.21 $22.05 $25.3694350 26 $11.74 $11.15 $12.8294350 $34.95 $33.20 $38.1894360 $36.96 $35.11 $40.3894360 TC $25.22 $23.96 $27.5594360 26 $11.74 $11.15 $12.8294370 $32.94 $31.29 $35.9894370 TC $21.20 $20.14 $23.1694370 26 $11.74 $11.15 $12.8294375 $32.81 $31.17 $35.8594375 TC $18.84 $17.90 $20.5994375 26 $13.97 $13.27 $15.2694400 $46.60 $44.27 $50.9194400 TC $27.91 $26.51 $30.4994400 26 $18.68 $17.75 $20.4194450 $44.93 $42.68 $49.0894450 TC $26.92 $25.57 $29.4194450 26 $18.01 $17.11 $19.6894452 26 $14.31 $13.59 $15.6394452 $47.28 $44.92 $51.6694452 TC $32.97 $31.32 $36.0294453 26 $18.35 $17.43 $20.0494453 $66.47 $63.15 $72.6294453 TC $48.12 $45.71 $52.5794610 $59.86 $56.87 $65.4094620 $95.64 $90.86 $104.4994620 TC $66.27 $62.96 $72.40

94620 26 $29.38 $27.91 $32.1094621 $136.29 $129.48 $148.9094621 TC $70.64 $67.11 $77.1894621 26 $65.65 $62.37 $71.7394640 $11.44 $10.87 $12.5094644 $31.63 $30.05 $34.5694645 $12.11 $11.50 $13.2394660 $50.32 $47.80 $54.97

# 94660 $34.51 $32.78 $37.7094662 $34.17 $32.46 $37.3394664 $12.44 $11.82 $13.5994667 $19.50 $18.53 $21.3194668 $16.15 $15.34 $17.6494680 $67.25 $63.89 $73.4794680 TC $55.51 $52.73 $60.6494680 26 $11.74 $11.15 $12.8294681 $83.85 $79.66 $91.6194681 TC $74.67 $70.94 $81.5894681 26 $9.17 $8.71 $10.0294690 $62.83 $59.69 $68.6494690 TC $59.55 $56.57 $65.0694690 26 $3.28 $3.12 $3.5994720 $46.05 $43.75 $50.3194720 TC $34.31 $32.59 $37.4894720 26 $11.74 $11.15 $12.8294725 $94.83 $90.09 $103.6094725 TC $83.09 $78.94 $90.7894725 26 $11.74 $11.15 $12.8294750 $57.75 $54.86 $63.0994750 26 $10.65 $10.12 $11.6494750 TC $47.10 $44.75 $51.4694760 $2.35 $2.23 $2.5694761 $4.69 $4.46 $5.1394762 $22.18 $21.07 $24.2394770 26 $6.61 $6.28 $7.2294770 TC $26.56 $25.23 $29.0194770 $33.17 $31.51 $36.2495004 $4.37 $4.15 $4.7795010 $15.69 $14.91 $17.15

# 95010 $7.28 $6.92 $7.9695012 $16.49 $15.67 $18.0295015 $10.64 $10.11 $11.63

# 95015 $7.28 $6.92 $7.9695024 $6.05 $5.75 $6.6195027 $6.05 $5.75 $6.6195028 $8.75 $8.31 $9.5695044 $6.73 $6.39 $7.3595052 $8.07 $7.67 $8.8295056 $14.80 $14.06 $16.17

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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95060 $15.47 $14.70 $16.9195065 $10.77 $10.23 $11.7695070 $64.94 $61.69 $70.9495071 $81.77 $77.68 $89.3395075 $59.46 $56.49 $64.96

# 95075 $44.99 $42.74 $49.1595115 $12.45 $11.83 $13.60

# 95115 $10.43 $9.91 $11.4095117 $15.47 $14.70 $16.91

# 95117 $13.46 $12.79 $14.7195144 $9.30 $8.84 $10.17

# 95144 $2.90 $2.76 $3.1795145 $13.33 $12.66 $14.56

# 95145 $2.90 $2.76 $3.1795146 $18.72 $17.78 $20.45

# 95146 $3.24 $3.08 $3.5495147 $18.38 $17.46 $20.08

# 95147 $2.90 $2.76 $3.1795148 $24.78 $23.54 $27.07

# 95148 $3.24 $3.08 $3.5495149 $32.85 $31.21 $35.89

# 95149 $3.24 $3.08 $3.5495165 $9.30 $8.84 $10.17

# 95165 $2.90 $2.76 $3.1795170 $7.28 $6.92 $7.96

# 95170 $3.24 $3.08 $3.5495180 $134.54 $127.81 $146.98

# 95180 $99.54 $94.56 $108.7495250 $133.26 $126.60 $145.5995251 $36.54 $34.71 $39.9295805 $573.09 $544.44 $626.1195805 TC $485.17 $460.91 $530.0595805 26 $87.91 $83.51 $96.0495806 $185.91 $176.61 $203.1095806 TC $108.94 $103.49 $119.0195806 26 $76.97 $73.12 $84.0995807 $470.92 $447.37 $514.4895807 TC $394.62 $374.89 $431.1295807 26 $76.30 $72.49 $83.3695808 $572.61 $543.98 $625.5895808 TC $448.80 $426.36 $490.3195808 26 $123.81 $117.62 $135.2695810 $730.08 $693.58 $797.6295810 TC $566.59 $538.26 $619.0095810 26 $163.50 $155.33 $178.6395811 26 $175.62 $166.84 $191.8795811 TC $624.13 $592.92 $681.8695811 $799.75 $759.76 $873.7295812 $193.53 $183.85 $211.43

95812 TC $140.64 $133.61 $153.6595812 26 $52.90 $50.26 $57.8095813 TC $163.52 $155.34 $178.6495813 26 $84.00 $79.80 $91.7795813 $247.52 $235.14 $270.4195816 TC $127.18 $120.82 $138.9495816 26 $52.90 $50.26 $57.8095816 $180.07 $171.07 $196.7395819 $168.63 $160.20 $184.2395819 TC $115.74 $109.95 $126.4495819 26 $52.90 $50.26 $57.8095822 $205.30 $195.04 $224.3095822 TC $152.41 $144.79 $166.5195822 26 $52.90 $50.26 $57.8095824 26 $36.48 $34.66 $39.8695827 $207.66 $197.28 $226.8795827 26 $51.22 $48.66 $55.9695827 TC $156.44 $148.62 $170.9195829 $1,222.93 $1,161.78 $1,336.0595829 TC $921.75 $875.66 $1,007.0195829 26 $301.18 $286.12 $329.0495830 $169.68 $161.20 $185.38

# 95830 $83.86 $79.67 $91.6295831 $24.62 $23.39 $26.90

# 95831 $13.85 $13.16 $15.1395832 $21.96 $20.86 $23.99

# 95832 $14.56 $13.83 $15.9095833 $35.09 $33.34 $38.34

# 95833 $23.65 $22.47 $25.8495834 $41.99 $39.89 $45.87

# 95834 $30.21 $28.70 $33.0195851 $17.08 $16.23 $18.66

# 95851 $7.99 $7.59 $8.7395852 $12.54 $11.91 $13.70

# 95852 $5.81 $5.52 $6.3595857 $39.05 $37.10 $42.67

# 95857 $26.26 $24.95 $28.6995860 TC $32.97 $31.32 $36.0295860 26 $47.72 $45.33 $52.1395860 $80.69 $76.66 $88.1695861 $106.82 $101.48 $116.7095861 TC $30.27 $28.76 $33.0795861 26 $76.55 $72.72 $83.6395863 $128.91 $122.46 $140.8395863 TC $37.00 $35.15 $40.4295863 26 $91.91 $87.31 $100.4195864 $159.98 $151.98 $174.7895864 TC $61.89 $58.80 $67.6295864 26 $98.10 $93.20 $107.18

95865 TC $25.57 $24.29 $27.9395865 26 $79.66 $75.68 $87.0395865 $105.23 $99.97 $114.9795866 TC $13.79 $13.10 $15.0795866 26 $62.28 $59.17 $68.0595866 $76.07 $72.27 $83.1195867 $62.22 $59.11 $67.9895867 TC $23.54 $22.36 $25.7195867 26 $38.68 $36.75 $42.2695868 $85.91 $81.61 $93.8595868 TC $28.25 $26.84 $30.8795868 26 $57.66 $54.78 $63.0095869 $31.68 $30.10 $34.6295869 TC $13.46 $12.79 $14.7195869 26 $18.22 $17.31 $19.9195870 $31.68 $30.10 $34.6295870 TC $13.46 $12.79 $14.7195870 26 $18.22 $17.31 $19.9195872 $147.92 $140.52 $161.6095872 TC $23.21 $22.05 $25.3695872 26 $124.72 $118.48 $136.2595873 $31.00 $29.45 $33.8795873 TC $12.78 $12.14 $13.9695873 26 $18.22 $17.31 $19.9195874 TC $12.78 $12.14 $13.9695874 26 $18.56 $17.63 $20.2795874 $31.34 $29.77 $34.2495875 TC $34.98 $33.23 $38.2195875 26 $53.66 $50.98 $58.6395875 $88.64 $84.21 $96.8495900 $55.45 $52.68 $60.5895900 TC $34.66 $32.93 $37.8795900 26 $20.79 $19.75 $22.7195903 $60.83 $57.79 $66.4695903 TC $31.29 $29.73 $34.1995903 26 $29.54 $28.06 $32.2795904 26 $17.13 $16.27 $18.7195904 $47.74 $45.35 $52.1595904 TC $30.62 $29.09 $33.4595920 26 $106.62 $101.29 $116.4895920 $151.36 $143.79 $165.3695920 TC $44.74 $42.50 $48.8895921 $60.29 $57.28 $65.8795921 TC $17.83 $16.94 $19.4895921 26 $42.46 $40.34 $46.3995922 $68.58 $65.15 $74.9295922 TC $21.87 $20.78 $23.9095922 26 $46.71 $44.37 $51.0395923 $100.00 $95.00 $109.25

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

95923 TC $55.86 $53.07 $61.0395923 26 $44.14 $41.93 $48.2295925 26 $26.97 $25.62 $29.4695925 $76.76 $72.92 $83.8695925 TC $49.79 $47.30 $54.4095926 26 $26.64 $25.31 $29.1195926 $75.08 $71.33 $82.0395926 TC $48.44 $46.02 $52.9295927 $76.76 $72.92 $83.8695927 TC $49.12 $46.66 $53.6695927 26 $27.64 $26.26 $30.2095928 $163.54 $155.36 $178.6695928 TC $90.18 $85.67 $98.5295928 26 $73.35 $69.68 $80.1395929 $171.28 $162.72 $187.1395929 TC $97.58 $92.70 $106.6195929 26 $73.69 $70.01 $80.5195930 $91.50 $86.93 $99.9795930 TC $74.37 $70.65 $81.2595930 26 $17.13 $16.27 $18.7195933 $58.42 $55.50 $63.8395933 TC $29.60 $28.12 $32.3495933 26 $28.82 $27.38 $31.4995934 $37.28 $35.42 $40.7395934 TC $12.11 $11.50 $13.2395934 26 $25.17 $23.91 $27.5095936 26 $26.97 $25.62 $29.4695936 TC $9.75 $9.26 $10.6595936 $36.73 $34.89 $40.1295937 $48.20 $45.79 $52.6695937 TC $15.14 $14.38 $16.5495937 26 $33.06 $31.41 $36.1295950 $209.22 $198.76 $228.5795950 TC $135.15 $128.39 $147.6595950 26 $74.06 $70.36 $80.9195951 $924.38 $878.16 $1,009.8895951 TC $609.10 $578.65 $665.4595951 26 $293.69 $279.01 $320.8695953 $385.64 $366.36 $421.3195953 TC $226.69 $215.36 $247.6695953 26 $158.95 $151.00 $173.6595954 $237.11 $225.25 $259.0495954 TC $118.78 $112.84 $129.7795954 26 $118.33 $112.41 $129.2795955 $123.60 $117.42 $135.0395955 TC $76.00 $72.20 $83.0395955 26 $47.60 $45.22 $52.0095956 26 $150.70 $143.17 $164.6595956 $645.26 $613.00 $704.95

95956 TC $494.57 $469.84 $540.3295957 26 $97.38 $92.51 $106.3995957 TC $91.16 $86.60 $99.5995957 $188.54 $179.11 $205.9895958 $298.75 $283.81 $326.3895958 TC $93.18 $88.52 $101.8095958 26 $205.57 $195.29 $224.5895961 $212.07 $201.47 $231.6995961 TC $53.82 $51.13 $58.8095961 26 $158.25 $150.34 $172.8995962 26 $163.27 $155.11 $178.3895962 $209.69 $199.21 $229.0995962 TC $46.42 $44.10 $50.7295965 26 $393.49 $373.82 $429.8995966 26 $195.22 $185.46 $213.2895967 26 $162.36 $154.24 $177.3895970 $45.10 $42.85 $49.28

# 95970 $20.87 $19.83 $22.8095971 $51.07 $48.52 $55.80

# 95971 $36.27 $34.46 $39.6395972 $96.55 $91.72 $105.48

# 95972 $71.98 $68.38 $78.6495973 $54.32 $51.60 $59.34

# 95973 $44.56 $42.33 $48.6895974 $163.19 $155.03 $178.28

# 95974 $147.71 $140.32 $161.3795975 $90.93 $86.38 $99.34

# 95975 $84.53 $80.30 $92.3595978 $189.66 $180.18 $207.21

# 95978 $167.11 $158.75 $182.5695979 $87.02 $82.67 $95.07

# 95979 $80.29 $76.28 $87.7295990 $53.49 $50.82 $58.4495991 $79.64 $75.66 $87.0196000 $83.24 $79.08 $90.9496001 $97.68 $92.80 $106.7296002 $19.40 $18.43 $21.1996003 $17.55 $16.67 $19.1796004 $104.70 $99.47 $114.3996020 26 $34.61 $32.88 $37.8196101 $84.48 $80.26 $92.30

# 96101 $83.80 $79.61 $91.5596102 $44.31 $42.09 $48.40

# 96102 $22.44 $21.32 $24.5296103 $34.59 $32.86 $37.79

# 96103 $23.15 $21.99 $25.2996105 $67.59 $64.21 $73.8496110 $12.06 $11.46 $13.1896111 $126.99 $120.64 $138.74

# 96111 $125.64 $119.36 $137.2696116 $94.87 $90.13 $103.65

# 96116 $89.15 $84.69 $97.3996118 $111.36 $105.79 $121.66

# 96118 $88.14 $83.73 $96.2996119 $63.27 $60.11 $69.13

# 96119 $30.29 $28.78 $33.1096120 $53.10 $50.45 $58.02

# 96120 $23.15 $21.99 $25.2996150 $22.77 $21.63 $24.8796151 $22.01 $20.91 $24.05

# 96151 $21.68 $20.60 $23.6996152 $20.92 $19.87 $22.85

# 96152 $20.58 $19.55 $22.4896153 $5.09 $4.84 $5.57

# 96153 $4.75 $4.51 $5.1996154 $20.54 $19.51 $22.44

# 96154 $20.20 $19.19 $22.0796401 $52.63 $50.00 $57.5096402 $38.41 $36.49 $41.9696405 $110.01 $104.51 $120.19

# 96405 $26.89 $25.55 $29.3896406 $131.94 $125.34 $144.14

# 96406 $38.05 $36.15 $41.5796409 $107.26 $101.90 $117.1996411 $61.99 $58.89 $67.7296413 $148.44 $141.02 $162.1796415 $33.68 $32.00 $36.8096416 $160.30 $152.29 $175.1396417 $73.14 $69.48 $79.9096420 $98.21 $93.30 $107.3096422 $162.15 $154.04 $177.1596423 $69.96 $66.46 $76.4396425 $159.12 $151.16 $173.8396440 $338.12 $321.21 $369.39

# 96440 $125.77 $119.48 $137.4096445 $328.07 $311.67 $358.42

# 96445 $117.40 $111.53 $128.2696450 $272.36 $258.74 $297.55

# 96450 $95.01 $90.26 $103.8096521 $130.35 $123.83 $142.4096522 $98.72 $93.78 $107.8596523 $24.73 $23.49 $27.0196542 $164.69 $156.46 $179.93

# 96542 $47.24 $44.88 $51.6196567 $82.10 $78.00 $89.7096570 $53.98 $51.28 $58.9796571 $25.96 $24.66 $28.3696900 $16.48 $15.66 $18.01

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

96904 $62.25 $59.14 $68.0196910 $43.06 $40.91 $47.0596912 $55.18 $52.42 $60.2896913 $76.36 $72.54 $83.4296920 $133.93 $127.23 $146.31

# 96920 $58.88 $55.94 $64.3396921 $135.69 $128.91 $148.25

# 96921 $59.98 $56.98 $65.5396922 $199.83 $189.84 $218.32

# 96922 $97.53 $92.65 $106.5597001 $67.16 $63.80 $73.3797002 $35.60 $33.82 $38.8997003 $71.87 $68.28 $78.5297004 $42.67 $40.54 $46.6297012 $13.05 $12.40 $14.2697016 $13.13 $12.47 $14.3497018 $6.27 $5.96 $6.8597022 $14.09 $13.39 $15.4097024 $4.58 $4.35 $5.0097026 $4.25 $4.04 $4.6597028 $5.34 $5.07 $5.8397032 $14.39 $13.67 $15.7297033 $19.48 $18.51 $21.2997034 $12.92 $12.27 $14.1197035 $10.90 $10.36 $11.9197036 $21.59 $20.51 $23.5997110 $25.25 $23.99 $27.5997112 $26.26 $24.95 $28.6997113 $29.96 $28.46 $32.7397116 $22.39 $21.27 $24.4697124 $20.16 $19.15 $22.0297140 $23.86 $22.67 $26.0797150 $15.82 $15.03 $17.2897530 $26.93 $25.58 $29.4297532 $22.56 $21.43 $24.6497533 $23.91 $22.71 $26.1297535 $26.93 $25.58 $29.4297537 $24.58 $23.35 $26.8597542 $24.92 $23.67 $27.2297597 $47.29 $44.93 $51.67

# 97597 $39.21 $37.25 $42.8497598 $59.58 $56.60 $65.09

# 97598 $50.49 $47.97 $55.1797605 $31.35 $29.78 $34.25

# 97605 $25.97 $24.67 $28.3797606 $33.92 $32.22 $37.05

# 97606 $28.53 $27.10 $31.1797750 $26.59 $25.26 $29.0597755 $31.31 $29.74 $34.20

97760 $28.27 $26.86 $30.8997761 $25.59 $24.31 $27.9697762 $25.83 $24.54 $28.2297802 $28.62 $27.19 $31.27

# 97802 $28.28 $26.87 $30.9097803 $25.63 $24.35 $28.0097804 $13.72 $13.03 $14.9898925 $26.26 $24.95 $28.69

# 98925 $20.54 $19.51 $22.4498926 $36.44 $34.62 $39.81

# 98926 $30.72 $29.18 $33.5698927 $47.05 $44.70 $51.41

# 98927 $39.98 $37.98 $43.6898928 $55.76 $52.97 $60.92

# 98928 $47.35 $44.98 $51.7398929 $64.09 $60.89 $70.02

# 98929 $54.00 $51.30 $59.0098940 $23.23 $22.07 $25.38

# 98940 $19.53 $18.55 $21.3398941 $32.07 $30.47 $35.04

# 98941 $28.04 $26.64 $30.6498942 $42.34 $40.22 $46.25

# 98942 $37.97 $36.07 $41.4899082 $0.85 $0.81 $0.9399143 $59.82 $56.83 $65.35

# 99143 $37.97 $36.07 $41.4899144 $89.57 $85.09 $97.85

# 99144 $39.48 $37.51 $43.1499145 $22.24 $21.13 $24.30

# 99145 $9.81 $9.32 $10.7299148 $59.82 $56.83 $65.35

# 99148 $37.97 $36.07 $41.4899149 $89.57 $85.09 $97.85

# 99149 $39.48 $37.51 $43.1499150 $22.24 $21.13 $24.30

# 99150 $9.81 $9.32 $10.7299170 $119.38 $113.41 $130.42

# 99170 $80.34 $76.32 $87.7799175 $41.36 $39.29 $45.1899183 $188.57 $179.14 $206.01

# 99183 $108.14 $102.73 $118.1499185 $31.29 $29.73 $34.1999186 $71.54 $67.96 $78.1599195 $33.65 $31.97 $36.7799201 $33.32 $31.65 $36.40

# 99201 $21.21 $20.15 $23.1799202 $58.53 $55.60 $63.94

# 99202 $42.04 $39.94 $45.9399203 $86.89 $82.55 $94.93

# 99203 $64.67 $61.44 $70.6699204 $132.93 $126.28 $145.22

# 99204 $106.34 $101.02 $116.1799205 $167.23 $158.87 $182.70

# 99205 $139.30 $132.34 $152.1999211 $18.47 $17.55 $20.18

# 99211 $8.04 $7.64 $8.7999212 $34.33 $32.61 $37.50

# 99212 $21.54 $20.46 $23.5399213 $56.35 $53.53 $61.56

# 99213 $40.87 $38.83 $44.6599214 $85.51 $81.23 $93.41

# 99214 $64.31 $61.09 $70.2599215 $115.98 $110.18 $126.71

# 99215 $92.42 $87.80 $100.9799217 $63.42 $60.25 $69.2999218 $60.05 $57.05 $65.6199219 $99.32 $94.35 $108.5099220 $139.93 $132.93 $152.8799221 $82.53 $78.40 $90.1699222 $115.40 $109.63 $126.0799223 $168.52 $160.09 $184.1099231 $34.51 $32.78 $37.7099232 $61.83 $58.74 $67.5599233 $88.39 $83.97 $96.5799234 $120.78 $114.74 $131.9599235 $159.37 $151.40 $174.1199236 $198.60 $188.67 $216.9799238 $63.09 $59.94 $68.9399239 $91.37 $86.80 $99.8299241 $45.52 $43.24 $49.73

# 99241 $31.05 $29.50 $33.9399242 $84.53 $80.30 $92.35

# 99242 $65.01 $61.76 $71.0299243 $115.83 $110.04 $126.55

# 99243 $89.92 $85.42 $98.2399244 $171.01 $162.46 $186.83

# 99244 $141.06 $134.01 $154.1199245 $212.20 $201.59 $231.83

# 99245 $178.22 $169.31 $194.7199251 $44.53 $42.30 $48.6599252 $70.99 $67.44 $77.5699253 $105.21 $99.95 $114.9499254 $151.51 $143.93 $165.5299255 $188.54 $179.11 $205.9899281 $18.85 $17.91 $20.6099282 $36.32 $34.50 $39.6899283 $58.95 $56.00 $64.4099284 $107.65 $102.27 $117.61

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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New Mexico Disclosure

99285 $161.17 $153.11 $176.0899289 $217.45 $206.58 $237.5799290 $111.44 $105.87 $121.7599291 $244.62 $232.39 $267.25

# 99291 $202.55 $192.42 $221.2899292 $110.17 $104.66 $120.36

# 99292 $101.42 $96.35 $110.8099293 $732.70 $696.07 $800.4899294 $362.87 $344.73 $396.4499295 $840.76 $798.72 $918.5399296 $362.58 $344.45 $396.1299298 $128.55 $122.12 $140.4499299 $118.87 $112.93 $129.8799300 $114.46 $108.74 $125.0599304 $58.75 $55.81 $64.1899305 $78.15 $74.24 $85.3899306 $96.16 $91.35 $105.0599307 $30.55 $29.02 $33.3799308 $50.59 $48.06 $55.2799309 $71.04 $67.49 $77.6199310 $88.84 $84.40 $97.0699315 $55.13 $52.37 $60.2399316 $72.34 $68.72 $79.0399318 $58.75 $55.81 $64.1899324 $52.31 $49.69 $57.1499325 $76.47 $72.65 $83.5599326 $110.26 $104.75 $120.4699327 $145.15 $137.89 $158.5799328 $179.62 $170.64 $196.2499334 $40.23 $38.22 $43.9599335 $63.67 $60.49 $69.5699336 $98.22 $93.31 $107.3199337 $144.48 $137.26 $157.8599341 $51.97 $49.37 $56.7899342 $76.47 $72.65 $83.5599343 $110.93 $105.38 $121.1999344 $145.49 $138.22 $158.9599345 $179.62 $170.64 $196.2499347 $40.23 $38.22 $43.9599348 $63.67 $60.49 $69.5699349 $98.56 $93.63 $107.6799350 $145.49 $138.22 $158.9599354 $87.83 $83.44 $95.96

# 99354 $83.79 $79.60 $91.5499355 $87.16 $82.80 $95.22

# 99355 $82.78 $78.64 $90.4499356 $80.89 $76.85 $88.3899357 $81.22 $77.16 $88.7399431 $53.24 $50.58 $58.17

99432 $77.13 $73.27 $84.26# 99432 $57.61 $54.73 $62.94

99433 $28.28 $26.87 $30.9099435 $72.01 $68.41 $78.6799436 $67.97 $64.57 $74.2699440 $133.33 $126.66 $145.66G0101 $32.99 $31.34 $36.04G0102 $18.47 $17.55 $20.18

# G0102 $8.04 $7.64 $8.79G0104 $113.67 $107.99 $124.19

# G0104 $53.10 $50.45 $58.02G0105 $344.47 $327.25 $376.34G0105 53 $113.67 $107.99 $124.19

# G0105 $188.66 $179.23 $206.11# G0105 53 $53.10 $50.45 $58.02

G0106 26 $45.50 $43.23 $49.71G0106 $142.71 $135.57 $155.91G0106 TC $97.22 $92.36 $106.21G0108 $26.25 $24.94 $28.68G0109 $15.14 $14.38 $16.54G0117 $40.40 $38.38 $44.14G0118 $26.21 $24.90 $28.64G0120 26 $45.50 $43.23 $49.71G0120 TC $97.22 $92.36 $106.21G0120 $142.71 $135.57 $155.91G0121 $344.47 $327.25 $376.34G0121 53 $113.67 $107.99 $124.19

# G0121 53 $53.10 $50.45 $58.02# G0121 $188.66 $179.23 $206.11

G0124 $22.14 $21.03 $24.18G0127 $15.44 $14.67 $16.87

# G0127 $8.37 $7.95 $9.14G0128 $4.00 $3.80 $4.37G0130 $36.17 $34.36 $39.51G0130 TC $25.90 $24.61 $28.30G0130 26 $10.27 $9.76 $11.22G0141 $22.14 $21.03 $24.18G0166 $130.83 $124.29 $142.93G0168 $78.08 $74.18 $85.31

# G0168 $23.56 $22.38 $25.74G0179 $45.78 $43.49 $50.01G0180 $60.42 $57.40 $66.01G0181 $105.88 $100.59 $115.68G0182 $110.59 $105.06 $120.82G0202 TC $87.14 $82.78 $95.20G0202 26 $32.28 $30.67 $35.27G0202 $119.42 $113.45 $130.47G0204 $129.81 $123.32 $141.82G0204 TC $89.83 $85.34 $98.14

G0204 26 $39.98 $37.98 $43.68G0206 $104.62 $99.39 $114.30G0206 TC $72.34 $68.72 $79.03G0206 26 $32.28 $30.67 $35.27G0237 $14.46 $13.74 $15.80G0238 $15.14 $14.38 $16.54G0239 $11.77 $11.18 $12.86G0245 $58.20 $55.29 $63.58

# G0245 $41.71 $39.62 $45.56G0246 $34.00 $32.30 $37.15

# G0246 $21.21 $20.15 $23.17G0247 $36.57 $34.74 $39.95

# G0247 $24.45 $23.23 $26.71G0248 $195.52 $185.74 $213.60G0249 $120.47 $114.45 $131.62G0250 $8.75 $8.31 $9.56G0268 $42.71 $40.57 $46.66

# G0268 $29.25 $27.79 $31.96G0270 $25.63 $24.35 $28.00G0271 $13.72 $13.03 $14.98G0275 $12.37 $11.75 $13.51G0278 $12.37 $11.75 $13.51G0281 $10.44 $9.92 $11.41G0283 $10.44 $9.92 $11.41G0288 $282.29 $268.18 $308.41G0289 $84.31 $80.09 $92.10G0308 $710.81 $675.27 $776.56G0309 $593.64 $563.96 $648.55G0310 $466.80 $443.46 $509.98G0311 $492.70 $468.07 $538.28G0312 $407.77 $387.38 $445.49G0313 $323.90 $307.71 $353.87G0314 $432.01 $410.41 $471.97G0315 $357.77 $339.88 $390.86G0316 $282.15 $268.04 $308.25G0317 $270.78 $257.24 $295.83G0318 $223.77 $212.58 $244.47G0319 $177.14 $168.28 $193.52G0320 $575.80 $547.01 $629.06G0321 $402.05 $381.95 $439.24G0322 $350.37 $332.85 $382.78G0323 $219.06 $208.11 $239.33G0324 $19.49 $18.52 $21.30G0325 $11.99 $11.39 $13.10G0326 $13.47 $12.80 $14.72G0327 $7.95 $7.55 $8.68G0329 $6.94 $6.59 $7.58G0332 $66.30 $62.99 $72.44G0341 $336.79 $319.95 $367.94

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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2007

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

PROCEDURECODE/MOD

PARFEE

NONPAR CHARGEFEE FEE

New Mexico Disclosure

G0342 $631.29 $599.73 $689.69G0343 $1,038.96 $987.01 $1,135.06G0344 $87.22 $82.86 $95.29

# G0344 $65.01 $61.76 $71.02G0364 $11.69 $11.11 $12.78

# G0364 $8.66 $8.23 $9.46G0365 $160.71 $152.67 $175.57G0365 TC $149.01 $141.56 $162.79G0365 26 $11.70 $11.12 $12.79G0366 $22.50 $21.38 $24.59G0367 $14.46 $13.74 $15.80G0368 $8.04 $7.64 $8.79G0372 $16.11 $15.30 $17.60

# G0372 $8.04 $7.64 $8.79G0375 $11.70 $11.12 $12.79G0376 $22.35 $21.23 $24.41

# G0376 $22.01 $20.91 $24.05G0389 26 $27.10 $25.75 $29.61G0389 $82.94 $78.79 $90.61G0389 TC $55.84 $53.05 $61.01G0392 $2,159.52 $2,051.54 $2,359.27

# G0392 $461.05 $438.00 $503.70G0393 $1,645.31 $1,563.04 $1,797.50

# G0393 $292.80 $278.16 $319.88G9041 $23.57 $22.39 $25.75G9042 $11.15 $10.59 $12.18G9043 $11.15 $10.59 $12.18G9044 $9.80 $9.31 $10.71M0064 $28.99 $27.54 $31.67

# M0064 $16.54 $15.71 $18.07P3001 $22.14 $21.03 $24.18Q0035 26 $8.04 $7.64 $8.79Q0035 TC $12.78 $12.14 $13.96Q0035 $20.82 $19.78 $22.75Q0091 $36.39 $34.57 $39.76

# Q0091 $17.55 $16.67 $19.17Q0092 $12.11 $11.50 $13.23

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION.

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