|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
IP
|
$4,929.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,971.60 |
| Max. Negotiated Rate |
$4,682.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,943.20
|
| Rate for Payer: Cash Price |
$2,957.40
|
| Rate for Payer: Cash Price |
$2,957.40
|
| Rate for Payer: Cigna Commercial |
$4,189.65
|
| Rate for Payer: First Health Commercial |
$4,436.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,436.10
|
| Rate for Payer: GEHA Commercial |
$3,450.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,436.10
|
| Rate for Payer: Multiplan All |
$4,485.39
|
| Rate for Payer: OMNI Networks Commercial |
$3,450.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,436.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,682.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,696.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,583.97
|
| Rate for Payer: Zelis Auto |
$1,971.60
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
IP
|
$10,670.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7005213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.00 |
| Max. Negotiated Rate |
$10,136.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,536.00
|
| Rate for Payer: Cash Price |
$6,402.00
|
| Rate for Payer: Cash Price |
$6,402.00
|
| Rate for Payer: Cigna Commercial |
$9,069.50
|
| Rate for Payer: First Health Commercial |
$9,603.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,603.00
|
| Rate for Payer: GEHA Commercial |
$7,469.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,603.00
|
| Rate for Payer: Multiplan All |
$9,709.70
|
| Rate for Payer: OMNI Networks Commercial |
$7,469.00
|
| Rate for Payer: One Health Plan PPO/POS |
$9,603.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,136.50
|
| Rate for Payer: Three Rivers Provider Network All |
$8,002.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,923.10
|
| Rate for Payer: Zelis Auto |
$4,268.00
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
OP
|
$10,191.51
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,547.88 |
| Max. Negotiated Rate |
$9,681.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,114.91
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cigna Commercial |
$8,662.78
|
| Rate for Payer: First Health Commercial |
$9,172.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,172.36
|
| Rate for Payer: GEHA Commercial |
$8,153.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,172.36
|
| Rate for Payer: Humana ChoiceCare |
$2,649.79
|
| Rate for Payer: Multiplan All |
$9,274.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,114.91
|
| Rate for Payer: OMNI Networks Commercial |
$7,134.06
|
| Rate for Payer: One Health Plan PPO/POS |
$9,172.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,681.93
|
| Rate for Payer: Three Rivers Provider Network All |
$7,643.63
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,968.53
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,547.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,478.10
|
| Rate for Payer: Zelis Auto |
$4,076.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,095.76
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
IP
|
$10,191.51
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,076.60 |
| Max. Negotiated Rate |
$9,681.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,153.21
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cigna Commercial |
$8,662.78
|
| Rate for Payer: First Health Commercial |
$9,172.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,172.36
|
| Rate for Payer: GEHA Commercial |
$7,134.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,172.36
|
| Rate for Payer: Multiplan All |
$9,274.27
|
| Rate for Payer: OMNI Networks Commercial |
$7,134.06
|
| Rate for Payer: One Health Plan PPO/POS |
$9,172.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,681.93
|
| Rate for Payer: Three Rivers Provider Network All |
$7,643.63
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,478.10
|
| Rate for Payer: Zelis Auto |
$4,076.60
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
OP
|
$8,968.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,242.00 |
| Max. Negotiated Rate |
$8,519.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,380.80
|
| Rate for Payer: Cash Price |
$5,380.80
|
| Rate for Payer: Cash Price |
$5,380.80
|
| Rate for Payer: Cigna Commercial |
$7,622.80
|
| Rate for Payer: First Health Commercial |
$8,071.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,071.20
|
| Rate for Payer: GEHA Commercial |
$7,174.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,071.20
|
| Rate for Payer: Humana ChoiceCare |
$2,331.68
|
| Rate for Payer: Multiplan All |
$8,160.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,380.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,277.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,071.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,519.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,726.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,891.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,242.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,340.24
|
| Rate for Payer: Zelis Auto |
$3,587.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,484.00
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
IP
|
$8,968.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001877
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,587.20 |
| Max. Negotiated Rate |
$8,519.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,174.40
|
| Rate for Payer: Cash Price |
$5,380.80
|
| Rate for Payer: Cash Price |
$5,380.80
|
| Rate for Payer: Cigna Commercial |
$7,622.80
|
| Rate for Payer: First Health Commercial |
$8,071.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,071.20
|
| Rate for Payer: GEHA Commercial |
$6,277.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,071.20
|
| Rate for Payer: Multiplan All |
$8,160.88
|
| Rate for Payer: OMNI Networks Commercial |
$6,277.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,071.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,519.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,726.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,340.24
|
| Rate for Payer: Zelis Auto |
$3,587.20
|
|
|
IMPLT ALLOGRAFT PATELLA TENDON
|
Facility
|
OP
|
$10,191.51
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006812
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,547.88 |
| Max. Negotiated Rate |
$9,681.93 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,114.91
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cash Price |
$6,114.91
|
| Rate for Payer: Cigna Commercial |
$8,662.78
|
| Rate for Payer: First Health Commercial |
$9,172.36
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,172.36
|
| Rate for Payer: GEHA Commercial |
$8,153.21
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,172.36
|
| Rate for Payer: Humana ChoiceCare |
$2,649.79
|
| Rate for Payer: Multiplan All |
$9,274.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,114.91
|
| Rate for Payer: OMNI Networks Commercial |
$7,134.06
|
| Rate for Payer: One Health Plan PPO/POS |
$9,172.36
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,681.93
|
| Rate for Payer: Three Rivers Provider Network All |
$7,643.63
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,968.53
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,547.88
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,478.10
|
| Rate for Payer: Zelis Auto |
$4,076.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,095.76
|
|
|
IMPLT ALLOGRAFT TALUS RIGHT
|
Facility
|
IP
|
$20,022.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009249
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,008.93 |
| Max. Negotiated Rate |
$19,021.21 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16,017.86
|
| Rate for Payer: Cash Price |
$12,013.40
|
| Rate for Payer: Cash Price |
$12,013.40
|
| Rate for Payer: Cigna Commercial |
$17,018.98
|
| Rate for Payer: First Health Commercial |
$18,020.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18,020.10
|
| Rate for Payer: GEHA Commercial |
$14,015.63
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18,020.10
|
| Rate for Payer: Multiplan All |
$18,220.32
|
| Rate for Payer: OMNI Networks Commercial |
$14,015.63
|
| Rate for Payer: One Health Plan PPO/POS |
$18,020.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19,021.21
|
| Rate for Payer: Three Rivers Provider Network All |
$15,016.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18,620.77
|
| Rate for Payer: Zelis Auto |
$8,008.93
|
|
|
IMPLT ALLOGRAFT TALUS RIGHT
|
Facility
|
OP
|
$20,022.33
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009249
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,005.58 |
| Max. Negotiated Rate |
$19,021.21 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,013.40
|
| Rate for Payer: Cash Price |
$12,013.40
|
| Rate for Payer: Cash Price |
$12,013.40
|
| Rate for Payer: Cigna Commercial |
$17,018.98
|
| Rate for Payer: First Health Commercial |
$18,020.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18,020.10
|
| Rate for Payer: GEHA Commercial |
$16,017.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18,020.10
|
| Rate for Payer: Humana ChoiceCare |
$5,205.81
|
| Rate for Payer: Multiplan All |
$18,220.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12,013.40
|
| Rate for Payer: OMNI Networks Commercial |
$14,015.63
|
| Rate for Payer: One Health Plan PPO/POS |
$18,020.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19,021.21
|
| Rate for Payer: Three Rivers Provider Network All |
$15,016.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$17,619.65
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,005.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$18,620.77
|
| Rate for Payer: Zelis Auto |
$8,008.93
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10,011.17
|
|
|
IMPLT ALLOGRAFT TENDONOSIS SEMI
|
Facility
|
OP
|
$4,814.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.50 |
| Max. Negotiated Rate |
$4,573.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,888.40
|
| Rate for Payer: Cash Price |
$2,888.40
|
| Rate for Payer: Cash Price |
$2,888.40
|
| Rate for Payer: Cigna Commercial |
$4,091.90
|
| Rate for Payer: First Health Commercial |
$4,332.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,332.60
|
| Rate for Payer: GEHA Commercial |
$3,851.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,332.60
|
| Rate for Payer: Humana ChoiceCare |
$1,251.64
|
| Rate for Payer: Multiplan All |
$4,380.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,888.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,369.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,332.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,573.30
|
| Rate for Payer: Three Rivers Provider Network All |
$3,610.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,236.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,203.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,477.02
|
| Rate for Payer: Zelis Auto |
$1,925.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,407.00
|
|
|
IMPLT ALLOGRAFT TENDONOSIS SEMI
|
Facility
|
IP
|
$4,950.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,980.00 |
| Max. Negotiated Rate |
$4,702.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,960.00
|
| Rate for Payer: Cash Price |
$2,970.00
|
| Rate for Payer: Cash Price |
$2,970.00
|
| Rate for Payer: Cigna Commercial |
$4,207.50
|
| Rate for Payer: First Health Commercial |
$4,455.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,455.00
|
| Rate for Payer: GEHA Commercial |
$3,465.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,455.00
|
| Rate for Payer: Multiplan All |
$4,504.50
|
| Rate for Payer: OMNI Networks Commercial |
$3,465.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,455.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,702.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,712.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,603.50
|
| Rate for Payer: Zelis Auto |
$1,980.00
|
|
|
IMPLT ALLOGRAFT TENDONOSIS SEMI
|
Facility
|
OP
|
$4,950.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,702.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,970.00
|
| Rate for Payer: Cash Price |
$2,970.00
|
| Rate for Payer: Cash Price |
$2,970.00
|
| Rate for Payer: Cigna Commercial |
$4,207.50
|
| Rate for Payer: First Health Commercial |
$4,455.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,455.00
|
| Rate for Payer: GEHA Commercial |
$3,960.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,455.00
|
| Rate for Payer: Humana ChoiceCare |
$1,287.00
|
| Rate for Payer: Multiplan All |
$4,504.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,970.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,465.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,455.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,702.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,712.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,356.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,237.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,603.50
|
| Rate for Payer: Zelis Auto |
$1,980.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,475.00
|
|
|
IMPLT ALLOGRAFT TENDONOSIS SEMI
|
Facility
|
IP
|
$4,814.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,925.60 |
| Max. Negotiated Rate |
$4,573.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,851.20
|
| Rate for Payer: Cash Price |
$2,888.40
|
| Rate for Payer: Cash Price |
$2,888.40
|
| Rate for Payer: Cigna Commercial |
$4,091.90
|
| Rate for Payer: First Health Commercial |
$4,332.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,332.60
|
| Rate for Payer: GEHA Commercial |
$3,369.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,332.60
|
| Rate for Payer: Multiplan All |
$4,380.74
|
| Rate for Payer: OMNI Networks Commercial |
$3,369.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,332.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,573.30
|
| Rate for Payer: Three Rivers Provider Network All |
$3,610.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,477.02
|
| Rate for Payer: Zelis Auto |
$1,925.60
|
|
|
IMPLT ALLOGRAPH TENDON ACHILLES
|
Facility
|
OP
|
$6,503.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,625.75 |
| Max. Negotiated Rate |
$6,177.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,901.80
|
| Rate for Payer: Cash Price |
$3,901.80
|
| Rate for Payer: Cash Price |
$3,901.80
|
| Rate for Payer: Cigna Commercial |
$5,527.55
|
| Rate for Payer: First Health Commercial |
$5,852.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,852.70
|
| Rate for Payer: GEHA Commercial |
$5,202.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,852.70
|
| Rate for Payer: Humana ChoiceCare |
$1,690.78
|
| Rate for Payer: Multiplan All |
$5,917.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,901.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,552.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,852.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,177.85
|
| Rate for Payer: Three Rivers Provider Network All |
$4,877.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,722.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,625.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,047.79
|
| Rate for Payer: Zelis Auto |
$2,601.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,251.50
|
|
|
IMPLT ALLOGRAPH TENDON ACHILLES
|
Facility
|
IP
|
$6,503.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,601.20 |
| Max. Negotiated Rate |
$6,177.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,202.40
|
| Rate for Payer: Cash Price |
$3,901.80
|
| Rate for Payer: Cash Price |
$3,901.80
|
| Rate for Payer: Cigna Commercial |
$5,527.55
|
| Rate for Payer: First Health Commercial |
$5,852.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,852.70
|
| Rate for Payer: GEHA Commercial |
$4,552.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,852.70
|
| Rate for Payer: Multiplan All |
$5,917.73
|
| Rate for Payer: OMNI Networks Commercial |
$4,552.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,852.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,177.85
|
| Rate for Payer: Three Rivers Provider Network All |
$4,877.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,047.79
|
| Rate for Payer: Zelis Auto |
$2,601.20
|
|
|
IMPLT ALLOWRAP 2X2
|
Facility
|
OP
|
$4,872.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Humana ChoiceCare |
$1,266.72
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,923.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,287.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,436.00
|
|
|
IMPLT ALLOWRAP 2X2
|
Facility
|
IP
|
$4,872.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002957
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,948.80 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,897.60
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
|
|
IMPLT ALLOWRAP 2X4
|
Facility
|
IP
|
$5,556.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.40 |
| Max. Negotiated Rate |
$5,278.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,444.80
|
| Rate for Payer: Cash Price |
$3,333.60
|
| Rate for Payer: Cash Price |
$3,333.60
|
| Rate for Payer: Cigna Commercial |
$4,722.60
|
| Rate for Payer: First Health Commercial |
$5,000.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,000.40
|
| Rate for Payer: GEHA Commercial |
$3,889.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,000.40
|
| Rate for Payer: Multiplan All |
$5,055.96
|
| Rate for Payer: OMNI Networks Commercial |
$3,889.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,000.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,278.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,167.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,167.08
|
| Rate for Payer: Zelis Auto |
$2,222.40
|
|
|
IMPLT ALLOWRAP 2X4
|
Facility
|
OP
|
$5,556.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$5,278.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,333.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$3,333.60
|
| Rate for Payer: Cash Price |
$3,333.60
|
| Rate for Payer: Cash Price |
$3,333.60
|
| Rate for Payer: Cigna Commercial |
$4,722.60
|
| Rate for Payer: First Health Commercial |
$5,000.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,000.40
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,000.40
|
| Rate for Payer: Humana ChoiceCare |
$1,444.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$5,055.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,333.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,889.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,000.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,278.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,167.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,889.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,167.08
|
| Rate for Payer: Zelis Auto |
$2,222.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,778.00
|
|
|
IMPLT ALLOWRAP 4X6
|
Facility
|
OP
|
$13,094.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002959
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$12,439.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,856.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$7,856.40
|
| Rate for Payer: Cash Price |
$7,856.40
|
| Rate for Payer: Cash Price |
$7,856.40
|
| Rate for Payer: Cigna Commercial |
$11,129.90
|
| Rate for Payer: First Health Commercial |
$11,784.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,784.60
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,784.60
|
| Rate for Payer: Humana ChoiceCare |
$3,404.44
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$11,915.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,856.40
|
| Rate for Payer: OMNI Networks Commercial |
$9,165.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,784.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,439.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,820.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,522.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,177.42
|
| Rate for Payer: Zelis Auto |
$5,237.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,547.00
|
|
|
IMPLT ALLOWRAP 4X6
|
Facility
|
IP
|
$13,094.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002959
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,237.60 |
| Max. Negotiated Rate |
$12,439.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,475.20
|
| Rate for Payer: Cash Price |
$7,856.40
|
| Rate for Payer: Cash Price |
$7,856.40
|
| Rate for Payer: Cigna Commercial |
$11,129.90
|
| Rate for Payer: First Health Commercial |
$11,784.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,784.60
|
| Rate for Payer: GEHA Commercial |
$9,165.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,784.60
|
| Rate for Payer: Multiplan All |
$11,915.54
|
| Rate for Payer: OMNI Networks Commercial |
$9,165.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,784.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,439.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,820.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,177.42
|
| Rate for Payer: Zelis Auto |
$5,237.60
|
|
|
IMPLT ALLOWRAP 4X8
|
Facility
|
OP
|
$17,202.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$16,341.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,321.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$36.22
|
| Rate for Payer: Cash Price |
$10,321.20
|
| Rate for Payer: Cash Price |
$10,321.20
|
| Rate for Payer: Cash Price |
$10,321.20
|
| Rate for Payer: Cigna Commercial |
$14,621.70
|
| Rate for Payer: First Health Commercial |
$15,481.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,481.80
|
| Rate for Payer: GEHA Commercial |
$33.25
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,481.80
|
| Rate for Payer: Humana ChoiceCare |
$4,472.52
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$36.96
|
| Rate for Payer: Multiplan All |
$15,653.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,321.20
|
| Rate for Payer: OMNI Networks Commercial |
$12,041.40
|
| Rate for Payer: One Health Plan PPO/POS |
$15,481.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$42.67
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$36.96
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,341.90
|
| Rate for Payer: Three Rivers Provider Network All |
$12,901.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15,137.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.96
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15,997.86
|
| Rate for Payer: Zelis Auto |
$6,880.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,601.00
|
|
|
IMPLT ALLOWRAP 4X8
|
Facility
|
IP
|
$17,202.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
7002960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,880.80 |
| Max. Negotiated Rate |
$16,341.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13,761.60
|
| Rate for Payer: Cash Price |
$10,321.20
|
| Rate for Payer: Cash Price |
$10,321.20
|
| Rate for Payer: Cigna Commercial |
$14,621.70
|
| Rate for Payer: First Health Commercial |
$15,481.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,481.80
|
| Rate for Payer: GEHA Commercial |
$12,041.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,481.80
|
| Rate for Payer: Multiplan All |
$15,653.82
|
| Rate for Payer: OMNI Networks Commercial |
$12,041.40
|
| Rate for Payer: One Health Plan PPO/POS |
$15,481.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,341.90
|
| Rate for Payer: Three Rivers Provider Network All |
$12,901.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15,997.86
|
| Rate for Payer: Zelis Auto |
$6,880.80
|
|
|
IMPLT AMS 700 CX MS PUMP IZ
|
Facility
|
OP
|
$27,028.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003334
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,757.00 |
| Max. Negotiated Rate |
$25,676.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$16,216.80
|
| Rate for Payer: Cash Price |
$16,216.80
|
| Rate for Payer: Cash Price |
$16,216.80
|
| Rate for Payer: Cigna Commercial |
$22,973.80
|
| Rate for Payer: First Health Commercial |
$24,325.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24,325.20
|
| Rate for Payer: GEHA Commercial |
$21,622.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24,325.20
|
| Rate for Payer: Humana ChoiceCare |
$7,027.28
|
| Rate for Payer: Multiplan All |
$24,595.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$16,216.80
|
| Rate for Payer: OMNI Networks Commercial |
$18,919.60
|
| Rate for Payer: One Health Plan PPO/POS |
$24,325.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25,676.60
|
| Rate for Payer: Three Rivers Provider Network All |
$20,271.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23,784.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,757.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25,136.04
|
| Rate for Payer: Zelis Auto |
$10,811.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13,514.00
|
|
|
IMPLT AMS 700 CX MS PUMP IZ
|
Facility
|
IP
|
$27,028.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003334
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,811.20 |
| Max. Negotiated Rate |
$25,676.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$21,622.40
|
| Rate for Payer: Cash Price |
$16,216.80
|
| Rate for Payer: Cash Price |
$16,216.80
|
| Rate for Payer: Cigna Commercial |
$22,973.80
|
| Rate for Payer: First Health Commercial |
$24,325.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$24,325.20
|
| Rate for Payer: GEHA Commercial |
$18,919.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$24,325.20
|
| Rate for Payer: Multiplan All |
$24,595.48
|
| Rate for Payer: OMNI Networks Commercial |
$18,919.60
|
| Rate for Payer: One Health Plan PPO/POS |
$24,325.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$25,676.60
|
| Rate for Payer: Three Rivers Provider Network All |
$20,271.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$25,136.04
|
| Rate for Payer: Zelis Auto |
$10,811.20
|
|
