|
IMPLT AUGMENT TIBIAL HALF BLOCK SIZE 5
|
Facility
|
IP
|
$3,609.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.60 |
| Max. Negotiated Rate |
$3,428.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,887.20
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cigna Commercial |
$3,067.65
|
| Rate for Payer: First Health Commercial |
$3,248.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,248.10
|
| Rate for Payer: GEHA Commercial |
$2,526.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,248.10
|
| Rate for Payer: Multiplan All |
$3,284.19
|
| Rate for Payer: OMNI Networks Commercial |
$2,526.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,248.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,428.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,706.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,356.37
|
| Rate for Payer: Zelis Auto |
$1,443.60
|
|
|
IMPLT AUGMENT TIBIAL HALF BLOCK SIZE 5
|
Facility
|
OP
|
$3,609.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$902.25 |
| Max. Negotiated Rate |
$3,428.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cigna Commercial |
$3,067.65
|
| Rate for Payer: First Health Commercial |
$3,248.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,248.10
|
| Rate for Payer: GEHA Commercial |
$2,887.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,248.10
|
| Rate for Payer: Humana ChoiceCare |
$938.34
|
| Rate for Payer: Multiplan All |
$3,284.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,165.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,526.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,248.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,428.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,706.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,175.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$902.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,356.37
|
| Rate for Payer: Zelis Auto |
$1,443.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,804.50
|
|
|
IMPLT AUGM TIBIAL BLOCK HALF SZ 6 LM/RL
|
Facility
|
IP
|
$3,499.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002897
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,399.60 |
| Max. Negotiated Rate |
$3,324.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,799.20
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cigna Commercial |
$2,974.15
|
| Rate for Payer: First Health Commercial |
$3,149.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,149.10
|
| Rate for Payer: GEHA Commercial |
$2,449.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,149.10
|
| Rate for Payer: Multiplan All |
$3,184.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,449.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,149.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,324.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,624.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,254.07
|
| Rate for Payer: Zelis Auto |
$1,399.60
|
|
|
IMPLT AUGM TIBIAL BLOCK HALF SZ 6 LM/RL
|
Facility
|
OP
|
$3,499.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002897
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.75 |
| Max. Negotiated Rate |
$3,324.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cigna Commercial |
$2,974.15
|
| Rate for Payer: First Health Commercial |
$3,149.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,149.10
|
| Rate for Payer: GEHA Commercial |
$2,799.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,149.10
|
| Rate for Payer: Humana ChoiceCare |
$909.74
|
| Rate for Payer: Multiplan All |
$3,184.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,099.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,449.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,149.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,324.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,624.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$874.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,254.07
|
| Rate for Payer: Zelis Auto |
$1,399.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,749.50
|
|
|
IMPLT AUGM TIBIAL BLOCK HALF SZ 6 RM/LL
|
Facility
|
OP
|
$3,499.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.75 |
| Max. Negotiated Rate |
$3,324.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cigna Commercial |
$2,974.15
|
| Rate for Payer: First Health Commercial |
$3,149.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,149.10
|
| Rate for Payer: GEHA Commercial |
$2,799.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,149.10
|
| Rate for Payer: Humana ChoiceCare |
$909.74
|
| Rate for Payer: Multiplan All |
$3,184.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,099.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,449.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,149.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,324.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,624.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,079.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$874.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,254.07
|
| Rate for Payer: Zelis Auto |
$1,399.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,749.50
|
|
|
IMPLT AUGM TIBIAL BLOCK HALF SZ 6 RM/LL
|
Facility
|
IP
|
$3,499.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,399.60 |
| Max. Negotiated Rate |
$3,324.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,799.20
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cash Price |
$2,099.40
|
| Rate for Payer: Cigna Commercial |
$2,974.15
|
| Rate for Payer: First Health Commercial |
$3,149.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,149.10
|
| Rate for Payer: GEHA Commercial |
$2,449.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,149.10
|
| Rate for Payer: Multiplan All |
$3,184.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,449.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,149.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,324.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,624.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,254.07
|
| Rate for Payer: Zelis Auto |
$1,399.60
|
|
|
IMPLT AWL-DIALATOR 5.5MM HEALICOIL
|
Facility
|
OP
|
$1,772.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$1,683.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,063.20
|
| Rate for Payer: Cash Price |
$1,063.20
|
| Rate for Payer: Cash Price |
$1,063.20
|
| Rate for Payer: Cigna Commercial |
$1,506.20
|
| Rate for Payer: First Health Commercial |
$1,594.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,594.80
|
| Rate for Payer: GEHA Commercial |
$1,417.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,594.80
|
| Rate for Payer: Humana ChoiceCare |
$460.72
|
| Rate for Payer: Multiplan All |
$1,612.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,063.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,240.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,594.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,683.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,329.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,559.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$443.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,647.96
|
| Rate for Payer: Zelis Auto |
$708.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$886.00
|
|
|
IMPLT AWL-DIALATOR 5.5MM HEALICOIL
|
Facility
|
IP
|
$1,772.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$708.80 |
| Max. Negotiated Rate |
$1,683.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,417.60
|
| Rate for Payer: Cash Price |
$1,063.20
|
| Rate for Payer: Cash Price |
$1,063.20
|
| Rate for Payer: Cigna Commercial |
$1,506.20
|
| Rate for Payer: First Health Commercial |
$1,594.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,594.80
|
| Rate for Payer: GEHA Commercial |
$1,240.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,594.80
|
| Rate for Payer: Multiplan All |
$1,612.52
|
| Rate for Payer: OMNI Networks Commercial |
$1,240.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,594.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,683.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,329.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,647.96
|
| Rate for Payer: Zelis Auto |
$708.80
|
|
|
IMPLT AXLE KNEE HINGE ROTATING MODULAR
|
Facility
|
OP
|
$3,359.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$839.75 |
| Max. Negotiated Rate |
$3,191.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,015.40
|
| Rate for Payer: Cash Price |
$2,015.40
|
| Rate for Payer: Cash Price |
$2,015.40
|
| Rate for Payer: Cigna Commercial |
$2,855.15
|
| Rate for Payer: First Health Commercial |
$3,023.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,023.10
|
| Rate for Payer: GEHA Commercial |
$2,687.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,023.10
|
| Rate for Payer: Humana ChoiceCare |
$873.34
|
| Rate for Payer: Multiplan All |
$3,056.69
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,015.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,351.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,023.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,191.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,519.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,955.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$839.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,123.87
|
| Rate for Payer: Zelis Auto |
$1,343.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,679.50
|
|
|
IMPLT AXLE KNEE HINGE ROTATING MODULAR
|
Facility
|
IP
|
$3,359.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,343.60 |
| Max. Negotiated Rate |
$3,191.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,687.20
|
| Rate for Payer: Cash Price |
$2,015.40
|
| Rate for Payer: Cash Price |
$2,015.40
|
| Rate for Payer: Cigna Commercial |
$2,855.15
|
| Rate for Payer: First Health Commercial |
$3,023.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,023.10
|
| Rate for Payer: GEHA Commercial |
$2,351.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,023.10
|
| Rate for Payer: Multiplan All |
$3,056.69
|
| Rate for Payer: OMNI Networks Commercial |
$2,351.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,023.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,191.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,519.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,123.87
|
| Rate for Payer: Zelis Auto |
$1,343.60
|
|
|
IMPLT BACTISURE WOUND LEVAGE
|
Facility
|
IP
|
$2,893.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,157.20 |
| Max. Negotiated Rate |
$2,748.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,314.40
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cigna Commercial |
$2,459.05
|
| Rate for Payer: First Health Commercial |
$2,603.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,603.70
|
| Rate for Payer: GEHA Commercial |
$2,025.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,603.70
|
| Rate for Payer: Multiplan All |
$2,632.63
|
| Rate for Payer: OMNI Networks Commercial |
$2,025.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,603.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,748.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,169.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,690.49
|
| Rate for Payer: Zelis Auto |
$1,157.20
|
|
|
IMPLT BACTISURE WOUND LEVAGE
|
Facility
|
OP
|
$2,893.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003310
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$723.25 |
| Max. Negotiated Rate |
$2,748.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cigna Commercial |
$2,459.05
|
| Rate for Payer: First Health Commercial |
$2,603.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,603.70
|
| Rate for Payer: GEHA Commercial |
$2,314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,603.70
|
| Rate for Payer: Humana ChoiceCare |
$752.18
|
| Rate for Payer: Multiplan All |
$2,632.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,735.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,025.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,603.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,748.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,169.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,545.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$723.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,690.49
|
| Rate for Payer: Zelis Auto |
$1,157.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,446.50
|
|
|
IMPLT BALL CARPAL WRIST NEUTRAL MEDIUM
|
Facility
|
IP
|
$4,860.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,944.00 |
| Max. Negotiated Rate |
$4,617.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,888.00
|
| Rate for Payer: Cash Price |
$2,916.00
|
| Rate for Payer: Cash Price |
$2,916.00
|
| Rate for Payer: Cigna Commercial |
$4,131.00
|
| Rate for Payer: First Health Commercial |
$4,374.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,374.00
|
| Rate for Payer: GEHA Commercial |
$3,402.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,374.00
|
| Rate for Payer: Multiplan All |
$4,422.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,402.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,374.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,617.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,645.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,519.80
|
| Rate for Payer: Zelis Auto |
$1,944.00
|
|
|
IMPLT BALL CARPAL WRIST NEUTRAL MEDIUM
|
Facility
|
OP
|
$4,860.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006552
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.00 |
| Max. Negotiated Rate |
$4,617.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,916.00
|
| Rate for Payer: Cash Price |
$2,916.00
|
| Rate for Payer: Cash Price |
$2,916.00
|
| Rate for Payer: Cigna Commercial |
$4,131.00
|
| Rate for Payer: First Health Commercial |
$4,374.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,374.00
|
| Rate for Payer: GEHA Commercial |
$3,888.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,374.00
|
| Rate for Payer: Humana ChoiceCare |
$1,263.60
|
| Rate for Payer: Multiplan All |
$4,422.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,916.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,402.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,374.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,617.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,645.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,276.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,215.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,519.80
|
| Rate for Payer: Zelis Auto |
$1,944.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,430.00
|
|
|
IMPLT BALLOON CRE 10,11,12MM GUIDEWIRE
|
Facility
|
OP
|
$1,114.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$278.50 |
| Max. Negotiated Rate |
$1,058.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$668.40
|
| Rate for Payer: Cash Price |
$668.40
|
| Rate for Payer: Cash Price |
$668.40
|
| Rate for Payer: Cigna Commercial |
$946.90
|
| Rate for Payer: First Health Commercial |
$1,002.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,002.60
|
| Rate for Payer: GEHA Commercial |
$891.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,002.60
|
| Rate for Payer: Humana ChoiceCare |
$289.64
|
| Rate for Payer: Multiplan All |
$1,013.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$668.40
|
| Rate for Payer: OMNI Networks Commercial |
$779.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,002.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,058.30
|
| Rate for Payer: Three Rivers Provider Network All |
$835.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$980.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$278.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,036.02
|
| Rate for Payer: Zelis Auto |
$445.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$557.00
|
|
|
IMPLT BALLOON CRE 10,11,12MM GUIDEWIRE
|
Facility
|
IP
|
$1,114.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.60 |
| Max. Negotiated Rate |
$1,058.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$891.20
|
| Rate for Payer: Cash Price |
$668.40
|
| Rate for Payer: Cash Price |
$668.40
|
| Rate for Payer: Cigna Commercial |
$946.90
|
| Rate for Payer: First Health Commercial |
$1,002.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,002.60
|
| Rate for Payer: GEHA Commercial |
$779.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,002.60
|
| Rate for Payer: Multiplan All |
$1,013.74
|
| Rate for Payer: OMNI Networks Commercial |
$779.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,002.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,058.30
|
| Rate for Payer: Three Rivers Provider Network All |
$835.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,036.02
|
| Rate for Payer: Zelis Auto |
$445.60
|
|
|
IMPLT BALLOON CRE 12,13.5,15MM GUIDEWIRE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$860.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
IMPLT BALLOON CRE 12,13.5,15MM GUIDEWIRE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.48 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
IMPLT BALLOON CRE 15,16.5,18 GUIDEWIRE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.00 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$860.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
|
|
IMPLT BALLOON CRE 15,16.5,18 GUIDEWIRE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$860.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
|
|
IMPLT BALLOON CRE 18,19,20MM GUIDEWIRE
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001705
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$645.00
|
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$860.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Humana ChoiceCare |
$279.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$645.00
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$946.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$268.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$537.50
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
IMPLT BALLOON CRE 18,19,20MM GUIDEWIRE
|
Facility
|
IP
|
$1,075.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001705
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.48 |
| Max. Negotiated Rate |
$1,021.25 |
| Rate for Payer: Cash Price |
$645.00
|
| Rate for Payer: Cigna Commercial |
$913.75
|
| Rate for Payer: First Health Commercial |
$967.50
|
| Rate for Payer: First Health Workers Compensation |
$415.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$967.50
|
| Rate for Payer: GEHA Commercial |
$752.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$967.50
|
| Rate for Payer: Multiplan All |
$978.25
|
| Rate for Payer: OMNI Networks Commercial |
$752.50
|
| Rate for Payer: One Health Plan PPO/POS |
$967.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,021.25
|
| Rate for Payer: Three Rivers Provider Network All |
$806.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$999.75
|
| Rate for Payer: Zelis Auto |
$430.00
|
| Rate for Payer: Zelis Worker's Compensation |
$293.48
|
|
|
IMPLT BALLOON DILATION GUIDED CT 6X20MM
|
Facility
|
OP
|
$5,451.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7006122
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$5,178.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,270.60
|
| Rate for Payer: Cash Price |
$3,270.60
|
| Rate for Payer: Cash Price |
$3,270.60
|
| Rate for Payer: Cigna Commercial |
$4,633.35
|
| Rate for Payer: First Health Commercial |
$4,905.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,905.90
|
| Rate for Payer: GEHA Commercial |
$4,360.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,905.90
|
| Rate for Payer: Humana ChoiceCare |
$1,417.26
|
| Rate for Payer: Multiplan All |
$4,960.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,270.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,815.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,905.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,178.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,088.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,796.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,362.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,069.43
|
| Rate for Payer: Zelis Auto |
$2,180.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,725.50
|
|
|
IMPLT BALLOON DILATION GUIDED CT 6X20MM
|
Facility
|
IP
|
$5,451.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7006122
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,180.40 |
| Max. Negotiated Rate |
$5,178.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,360.80
|
| Rate for Payer: Cash Price |
$3,270.60
|
| Rate for Payer: Cash Price |
$3,270.60
|
| Rate for Payer: Cigna Commercial |
$4,633.35
|
| Rate for Payer: First Health Commercial |
$4,905.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,905.90
|
| Rate for Payer: GEHA Commercial |
$3,815.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,905.90
|
| Rate for Payer: Multiplan All |
$4,960.41
|
| Rate for Payer: OMNI Networks Commercial |
$3,815.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,905.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,178.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,088.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,069.43
|
| Rate for Payer: Zelis Auto |
$2,180.40
|
|
|
IMPLT BALLOON DILATOR ACHALASIA 30MM
|
Facility
|
OP
|
$2,643.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.75 |
| Max. Negotiated Rate |
$2,510.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,585.80
|
| Rate for Payer: Cash Price |
$1,585.80
|
| Rate for Payer: Cash Price |
$1,585.80
|
| Rate for Payer: Cigna Commercial |
$2,246.55
|
| Rate for Payer: First Health Commercial |
$2,378.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,378.70
|
| Rate for Payer: GEHA Commercial |
$2,114.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,378.70
|
| Rate for Payer: Humana ChoiceCare |
$687.18
|
| Rate for Payer: Multiplan All |
$2,405.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,585.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,850.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,378.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,510.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,982.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,325.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$660.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,457.99
|
| Rate for Payer: Zelis Auto |
$1,057.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,321.50
|
|
