|
SCREW NON-LOCKING 2.4 X 16
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006809
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.50 |
| Max. Negotiated Rate |
$522.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$467.50
|
| Rate for Payer: First Health Commercial |
$495.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.00
|
| Rate for Payer: GEHA Commercial |
$440.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.00
|
| Rate for Payer: Humana ChoiceCare |
$143.00
|
| Rate for Payer: Multiplan All |
$500.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$330.00
|
| Rate for Payer: OMNI Networks Commercial |
$385.00
|
| Rate for Payer: One Health Plan PPO/POS |
$495.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.50
|
| Rate for Payer: Three Rivers Provider Network All |
$412.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$484.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.50
|
| Rate for Payer: Zelis Auto |
$220.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.00
|
|
|
SCREW NON-LOCKING 2.4 X 18
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006808
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.50 |
| Max. Negotiated Rate |
$522.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$467.50
|
| Rate for Payer: First Health Commercial |
$495.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.00
|
| Rate for Payer: GEHA Commercial |
$440.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.00
|
| Rate for Payer: Humana ChoiceCare |
$143.00
|
| Rate for Payer: Multiplan All |
$500.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$330.00
|
| Rate for Payer: OMNI Networks Commercial |
$385.00
|
| Rate for Payer: One Health Plan PPO/POS |
$495.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.50
|
| Rate for Payer: Three Rivers Provider Network All |
$412.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$484.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.50
|
| Rate for Payer: Zelis Auto |
$220.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$275.00
|
|
|
SCREW NON-LOCKING 2.4 X 18
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006808
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$220.00 |
| Max. Negotiated Rate |
$522.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$440.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$467.50
|
| Rate for Payer: First Health Commercial |
$495.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$495.00
|
| Rate for Payer: GEHA Commercial |
$385.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$495.00
|
| Rate for Payer: Multiplan All |
$500.50
|
| Rate for Payer: OMNI Networks Commercial |
$385.00
|
| Rate for Payer: One Health Plan PPO/POS |
$495.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$522.50
|
| Rate for Payer: Three Rivers Provider Network All |
$412.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$511.50
|
| Rate for Payer: Zelis Auto |
$220.00
|
|
|
SCREW VARIABLE ANGLE FIXATION
|
Facility
|
OP
|
$1,423.00
|
|
| Hospital Charge Code |
90061506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$355.75 |
| Max. Negotiated Rate |
$1,351.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$853.80
|
| Rate for Payer: Cash Price |
$853.80
|
| Rate for Payer: Cash Price |
$853.80
|
| Rate for Payer: Cigna Commercial |
$1,209.55
|
| Rate for Payer: First Health Commercial |
$1,280.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,280.70
|
| Rate for Payer: GEHA Commercial |
$1,138.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,280.70
|
| Rate for Payer: Humana ChoiceCare |
$369.98
|
| Rate for Payer: Multiplan All |
$1,294.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$853.80
|
| Rate for Payer: OMNI Networks Commercial |
$996.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,280.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,351.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,067.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,252.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$355.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,323.39
|
| Rate for Payer: Zelis Auto |
$569.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$711.50
|
|
|
SCREW VARIABLE ANGLE FIXATION
|
Facility
|
IP
|
$1,423.00
|
|
| Hospital Charge Code |
90061506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$569.20 |
| Max. Negotiated Rate |
$1,351.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,138.40
|
| Rate for Payer: Cash Price |
$853.80
|
| Rate for Payer: Cash Price |
$853.80
|
| Rate for Payer: Cigna Commercial |
$1,209.55
|
| Rate for Payer: First Health Commercial |
$1,280.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,280.70
|
| Rate for Payer: GEHA Commercial |
$996.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,280.70
|
| Rate for Payer: Multiplan All |
$1,294.93
|
| Rate for Payer: OMNI Networks Commercial |
$996.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,280.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,351.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,067.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,323.39
|
| Rate for Payer: Zelis Auto |
$569.20
|
|
|
SCREW VLP 2.4MM X 10MM LOCKING
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$600.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$525.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
|
|
SCREW VLP 2.4MM X 10MM LOCKING
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$600.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Humana ChoiceCare |
$195.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$450.00
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$660.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$375.00
|
|
|
SCREW VLP 2.4MM X 12MM
|
Facility
|
IP
|
$301.54
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008040
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$120.62 |
| Max. Negotiated Rate |
$286.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$241.23
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cigna Commercial |
$256.31
|
| Rate for Payer: First Health Commercial |
$271.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.39
|
| Rate for Payer: GEHA Commercial |
$211.08
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.39
|
| Rate for Payer: Multiplan All |
$274.40
|
| Rate for Payer: OMNI Networks Commercial |
$211.08
|
| Rate for Payer: One Health Plan PPO/POS |
$271.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.46
|
| Rate for Payer: Three Rivers Provider Network All |
$226.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.43
|
| Rate for Payer: Zelis Auto |
$120.62
|
|
|
SCREW VLP 2.4MM X 12MM
|
Facility
|
OP
|
$301.54
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008040
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.39 |
| Max. Negotiated Rate |
$286.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cigna Commercial |
$256.31
|
| Rate for Payer: First Health Commercial |
$271.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.39
|
| Rate for Payer: GEHA Commercial |
$241.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.39
|
| Rate for Payer: Humana ChoiceCare |
$78.40
|
| Rate for Payer: Multiplan All |
$274.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.92
|
| Rate for Payer: OMNI Networks Commercial |
$211.08
|
| Rate for Payer: One Health Plan PPO/POS |
$271.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.46
|
| Rate for Payer: Three Rivers Provider Network All |
$226.16
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.43
|
| Rate for Payer: Zelis Auto |
$120.62
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.77
|
|
|
SCREW VLP 2.4MM X 12MM LOCKING
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$600.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$525.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
|
|
SCREW VLP 2.4MM X 12MM LOCKING
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$600.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Humana ChoiceCare |
$195.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$450.00
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$660.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$375.00
|
|
|
SCREW VLP 2.4MM X 14MM
|
Facility
|
IP
|
$301.54
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008041
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$120.62 |
| Max. Negotiated Rate |
$286.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$241.23
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cigna Commercial |
$256.31
|
| Rate for Payer: First Health Commercial |
$271.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.39
|
| Rate for Payer: GEHA Commercial |
$211.08
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.39
|
| Rate for Payer: Multiplan All |
$274.40
|
| Rate for Payer: OMNI Networks Commercial |
$211.08
|
| Rate for Payer: One Health Plan PPO/POS |
$271.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.46
|
| Rate for Payer: Three Rivers Provider Network All |
$226.16
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.43
|
| Rate for Payer: Zelis Auto |
$120.62
|
|
|
SCREW VLP 2.4MM X 14MM
|
Facility
|
OP
|
$301.54
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008041
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.39 |
| Max. Negotiated Rate |
$286.46 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cash Price |
$180.92
|
| Rate for Payer: Cigna Commercial |
$256.31
|
| Rate for Payer: First Health Commercial |
$271.39
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$271.39
|
| Rate for Payer: GEHA Commercial |
$241.23
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$271.39
|
| Rate for Payer: Humana ChoiceCare |
$78.40
|
| Rate for Payer: Multiplan All |
$274.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$180.92
|
| Rate for Payer: OMNI Networks Commercial |
$211.08
|
| Rate for Payer: One Health Plan PPO/POS |
$271.39
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$286.46
|
| Rate for Payer: Three Rivers Provider Network All |
$226.16
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$75.39
|
| Rate for Payer: United Payors & United Providers UP&UP |
$280.43
|
| Rate for Payer: Zelis Auto |
$120.62
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$150.77
|
|
|
SCREW VLP 2.4MM X 14MM LOCKING
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$600.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$525.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
|
|
SCREW VLP 2.4MM X 14MM LOCKING
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$600.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Humana ChoiceCare |
$195.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$450.00
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$660.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$375.00
|
|
|
SCR PAP SMER; OBTAIN PREP&CONVY-LAB
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT Q0091
|
| Hospital Charge Code |
8500091
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$95.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
SCR PAP SMER; OBTAIN PREP&CONVY-LAB
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT Q0091
|
| Hospital Charge Code |
8500091
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$19.76 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$43.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$82.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$43.84
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$34.73
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$23.25
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$116.45
|
| Rate for Payer: First Health Commercial |
$123.30
|
| Rate for Payer: First Health Workers Compensation |
$52.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$123.30
|
| Rate for Payer: GEHA Commercial |
$109.60
|
| Rate for Payer: GEHA Medicare |
$23.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$123.30
|
| Rate for Payer: Humana ChoiceCare |
$25.57
|
| Rate for Payer: Humana Medicare Advantage |
$23.25
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$39.06
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$35.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$23.25
|
| Rate for Payer: Multiplan All |
$124.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.52
|
| Rate for Payer: OMNI Networks Commercial |
$95.90
|
| Rate for Payer: One Health Plan PPO/POS |
$123.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$40.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$35.44
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$23.25
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$130.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$46.50
|
| Rate for Payer: Three Rivers Provider Network All |
$102.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22.79
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$127.41
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$23.25
|
| Rate for Payer: Zelis Auto |
$54.80
|
| Rate for Payer: Zelis Medicare |
$19.76
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$27.90
|
| Rate for Payer: Zelis Worker's Compensation |
$37.40
|
|
|
SC THER INFUSION, RESET PUMP
|
Facility
|
IP
|
$386.00
|
|
|
Service Code
|
CPT 96371
|
| Hospital Charge Code |
8596371
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$105.38 |
| Max. Negotiated Rate |
$366.70 |
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$328.10
|
| Rate for Payer: First Health Commercial |
$347.40
|
| Rate for Payer: First Health Workers Compensation |
$149.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$347.40
|
| Rate for Payer: GEHA Commercial |
$270.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$347.40
|
| Rate for Payer: Multiplan All |
$351.26
|
| Rate for Payer: OMNI Networks Commercial |
$270.20
|
| Rate for Payer: One Health Plan PPO/POS |
$347.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$366.70
|
| Rate for Payer: Three Rivers Provider Network All |
$289.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.98
|
| Rate for Payer: Zelis Auto |
$154.40
|
| Rate for Payer: Zelis Worker's Compensation |
$105.38
|
|
|
SC THER INFUSION, RESET PUMP
|
Facility
|
OP
|
$386.00
|
|
|
Service Code
|
CPT 96371
|
| Hospital Charge Code |
8596371
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$366.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$231.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$67.58
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$328.10
|
| Rate for Payer: First Health Commercial |
$347.40
|
| Rate for Payer: First Health Workers Compensation |
$149.03
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$347.40
|
| Rate for Payer: GEHA Commercial |
$308.80
|
| Rate for Payer: GEHA Medicare |
$67.58
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$347.40
|
| Rate for Payer: Humana ChoiceCare |
$74.34
|
| Rate for Payer: Humana Medicare Advantage |
$67.58
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$113.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$67.58
|
| Rate for Payer: Multiplan All |
$351.26
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.89
|
| Rate for Payer: OMNI Networks Commercial |
$270.20
|
| Rate for Payer: One Health Plan PPO/POS |
$347.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$67.58
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$366.70
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$135.16
|
| Rate for Payer: Three Rivers Provider Network All |
$289.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.23
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$358.98
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$67.58
|
| Rate for Payer: Zelis Auto |
$154.40
|
| Rate for Payer: Zelis Medicare |
$57.44
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$81.10
|
| Rate for Payer: Zelis Worker's Compensation |
$105.38
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
CPT 54340
|
| Hospital Charge Code |
6154340
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$319.41 |
| Max. Negotiated Rate |
$6,549.86 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$702.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,794.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,274.93
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cigna Commercial |
$994.50
|
| Rate for Payer: First Health Commercial |
$1,053.00
|
| Rate for Payer: First Health Workers Compensation |
$451.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,053.00
|
| Rate for Payer: GEHA Commercial |
$936.00
|
| Rate for Payer: GEHA Medicare |
$3,274.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,053.00
|
| Rate for Payer: Humana ChoiceCare |
$3,602.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,274.93
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,501.88
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,851.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,274.93
|
| Rate for Payer: Multiplan All |
$1,064.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,567.38
|
| Rate for Payer: OMNI Networks Commercial |
$819.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,053.00
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,291.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,851.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,274.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,111.50
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,549.86
|
| Rate for Payer: Three Rivers Provider Network All |
$877.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,209.43
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,851.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,274.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,088.10
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,274.93
|
| Rate for Payer: Zelis Auto |
$468.00
|
| Rate for Payer: Zelis Medicare |
$2,783.69
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,929.92
|
| Rate for Payer: Zelis Worker's Compensation |
$319.41
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
CPT 54340
|
| Hospital Charge Code |
6154340
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$319.41 |
| Max. Negotiated Rate |
$1,111.50 |
| Rate for Payer: Cash Price |
$702.00
|
| Rate for Payer: Cigna Commercial |
$994.50
|
| Rate for Payer: First Health Commercial |
$1,053.00
|
| Rate for Payer: First Health Workers Compensation |
$451.74
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,053.00
|
| Rate for Payer: GEHA Commercial |
$819.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,053.00
|
| Rate for Payer: Multiplan All |
$1,064.70
|
| Rate for Payer: OMNI Networks Commercial |
$819.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,053.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,111.50
|
| Rate for Payer: Three Rivers Provider Network All |
$877.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,088.10
|
| Rate for Payer: Zelis Auto |
$468.00
|
| Rate for Payer: Zelis Worker's Compensation |
$319.41
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
IP
|
$2,091.00
|
|
|
Service Code
|
CPT 54348
|
| Hospital Charge Code |
6154348
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$570.84 |
| Max. Negotiated Rate |
$1,986.45 |
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$1,777.35
|
| Rate for Payer: First Health Commercial |
$1,881.90
|
| Rate for Payer: First Health Workers Compensation |
$807.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,881.90
|
| Rate for Payer: GEHA Commercial |
$1,463.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,881.90
|
| Rate for Payer: Multiplan All |
$1,902.81
|
| Rate for Payer: OMNI Networks Commercial |
$1,463.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,881.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,986.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,568.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,944.63
|
| Rate for Payer: Zelis Auto |
$836.40
|
| Rate for Payer: Zelis Worker's Compensation |
$570.84
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
OP
|
$2,163.00
|
|
|
Service Code
|
CPT 54344
|
| Hospital Charge Code |
6154344
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$590.50 |
| Max. Negotiated Rate |
$17,561.08 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,297.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,794.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$8,780.54
|
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cigna Commercial |
$1,838.55
|
| Rate for Payer: First Health Commercial |
$1,946.70
|
| Rate for Payer: First Health Workers Compensation |
$835.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,946.70
|
| Rate for Payer: GEHA Commercial |
$1,730.40
|
| Rate for Payer: GEHA Medicare |
$8,780.54
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,946.70
|
| Rate for Payer: Humana ChoiceCare |
$9,658.59
|
| Rate for Payer: Humana Medicare Advantage |
$8,780.54
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$14,751.31
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,851.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$8,780.54
|
| Rate for Payer: Multiplan All |
$1,968.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$14,926.92
|
| Rate for Payer: OMNI Networks Commercial |
$1,514.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,946.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,291.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,851.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$8,780.54
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,054.85
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$17,561.08
|
| Rate for Payer: Three Rivers Provider Network All |
$1,622.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,604.93
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,851.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,780.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,011.59
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$8,780.54
|
| Rate for Payer: Zelis Auto |
$865.20
|
| Rate for Payer: Zelis Medicare |
$7,463.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10,536.65
|
| Rate for Payer: Zelis Worker's Compensation |
$590.50
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
IP
|
$2,163.00
|
|
|
Service Code
|
CPT 54344
|
| Hospital Charge Code |
6154344
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$590.50 |
| Max. Negotiated Rate |
$2,054.85 |
| Rate for Payer: Cash Price |
$1,297.80
|
| Rate for Payer: Cigna Commercial |
$1,838.55
|
| Rate for Payer: First Health Commercial |
$1,946.70
|
| Rate for Payer: First Health Workers Compensation |
$835.13
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,946.70
|
| Rate for Payer: GEHA Commercial |
$1,514.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,946.70
|
| Rate for Payer: Multiplan All |
$1,968.33
|
| Rate for Payer: OMNI Networks Commercial |
$1,514.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,946.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,054.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,622.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,011.59
|
| Rate for Payer: Zelis Auto |
$865.20
|
| Rate for Payer: Zelis Worker's Compensation |
$590.50
|
|
|
SECONDARY URETHRAL SURGERY
|
Facility
|
OP
|
$2,091.00
|
|
|
Service Code
|
CPT 54348
|
| Hospital Charge Code |
6154348
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$570.84 |
| Max. Negotiated Rate |
$9,654.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,254.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,794.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4,827.10
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$1,777.35
|
| Rate for Payer: First Health Commercial |
$1,881.90
|
| Rate for Payer: First Health Workers Compensation |
$807.34
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,881.90
|
| Rate for Payer: GEHA Commercial |
$1,672.80
|
| Rate for Payer: GEHA Medicare |
$4,827.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,881.90
|
| Rate for Payer: Humana ChoiceCare |
$5,309.81
|
| Rate for Payer: Humana Medicare Advantage |
$4,827.10
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8,109.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,851.04
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4,827.10
|
| Rate for Payer: Multiplan All |
$1,902.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,206.07
|
| Rate for Payer: OMNI Networks Commercial |
$1,463.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,881.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$3,291.92
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,851.04
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4,827.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,986.45
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9,654.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,568.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,730.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,851.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,827.10
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,944.63
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4,827.10
|
| Rate for Payer: Zelis Auto |
$836.40
|
| Rate for Payer: Zelis Medicare |
$4,103.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,792.52
|
| Rate for Payer: Zelis Worker's Compensation |
$570.84
|
|
