|
IMPLT CATH CHEST TUBE 8 FR
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
70006377
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$38.25
|
| Rate for Payer: First Health Commercial |
$40.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$40.50
|
| Rate for Payer: GEHA Commercial |
$36.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$40.50
|
| Rate for Payer: Humana ChoiceCare |
$11.70
|
| Rate for Payer: Multiplan All |
$40.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$27.00
|
| Rate for Payer: OMNI Networks Commercial |
$31.50
|
| Rate for Payer: One Health Plan PPO/POS |
$40.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$42.75
|
| Rate for Payer: Three Rivers Provider Network All |
$33.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$11.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$41.85
|
| Rate for Payer: Zelis Auto |
$18.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$22.50
|
|
|
IMPLT CATH DAWSON DRAINAGE 12.0FR
|
Facility
|
OP
|
$524.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$131.00 |
| Max. Negotiated Rate |
$497.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$314.40
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$445.40
|
| Rate for Payer: First Health Commercial |
$471.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$471.60
|
| Rate for Payer: GEHA Commercial |
$419.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$471.60
|
| Rate for Payer: Humana ChoiceCare |
$136.24
|
| Rate for Payer: Multiplan All |
$476.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$314.40
|
| Rate for Payer: OMNI Networks Commercial |
$366.80
|
| Rate for Payer: One Health Plan PPO/POS |
$471.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$497.80
|
| Rate for Payer: Three Rivers Provider Network All |
$393.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$461.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$131.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$487.32
|
| Rate for Payer: Zelis Auto |
$209.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$262.00
|
|
|
IMPLT CATH DAWSON DRAINAGE 12.0FR
|
Facility
|
IP
|
$524.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$209.60 |
| Max. Negotiated Rate |
$497.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$419.20
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$445.40
|
| Rate for Payer: First Health Commercial |
$471.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$471.60
|
| Rate for Payer: GEHA Commercial |
$366.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$471.60
|
| Rate for Payer: Multiplan All |
$476.84
|
| Rate for Payer: OMNI Networks Commercial |
$366.80
|
| Rate for Payer: One Health Plan PPO/POS |
$471.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$497.80
|
| Rate for Payer: Three Rivers Provider Network All |
$393.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$487.32
|
| Rate for Payer: Zelis Auto |
$209.60
|
|
|
IMPLT CATH DRAINAGE BILIARY 12.0
|
Facility
|
IP
|
$622.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$248.80 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$497.60
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$435.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
|
|
IMPLT CATH DRAINAGE BILIARY 12.0
|
Facility
|
OP
|
$622.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$497.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Humana ChoiceCare |
$161.72
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$373.20
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$547.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$155.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$311.00
|
|
|
IMPLT CATH DRAINAGE BILIARY 14.0
|
Facility
|
IP
|
$622.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$248.80 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$497.60
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$435.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
|
|
IMPLT CATH DRAINAGE BILIARY 14.0
|
Facility
|
OP
|
$622.00
|
|
|
Service Code
|
CPT C1729
|
| Hospital Charge Code |
7001680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$590.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$528.70
|
| Rate for Payer: First Health Commercial |
$559.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$559.80
|
| Rate for Payer: GEHA Commercial |
$497.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$559.80
|
| Rate for Payer: Humana ChoiceCare |
$161.72
|
| Rate for Payer: Multiplan All |
$566.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$373.20
|
| Rate for Payer: OMNI Networks Commercial |
$435.40
|
| Rate for Payer: One Health Plan PPO/POS |
$559.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$590.90
|
| Rate for Payer: Three Rivers Provider Network All |
$466.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$547.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$155.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$578.46
|
| Rate for Payer: Zelis Auto |
$248.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$311.00
|
|
|
IMPLT CATHETER 8FR URETERAL W/ADAPT
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$72.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Humana ChoiceCare |
$23.66
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$54.60
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$80.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$22.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$45.50
|
|
|
IMPLT CATHETER 8FR URETERAL W/ADAPT
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$72.80
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$77.35
|
| Rate for Payer: First Health Commercial |
$81.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$81.90
|
| Rate for Payer: GEHA Commercial |
$63.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$81.90
|
| Rate for Payer: Multiplan All |
$82.81
|
| Rate for Payer: OMNI Networks Commercial |
$63.70
|
| Rate for Payer: One Health Plan PPO/POS |
$81.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$86.45
|
| Rate for Payer: Three Rivers Provider Network All |
$68.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$84.63
|
| Rate for Payer: Zelis Auto |
$36.40
|
|
|
IMPLT CATHETER GROSHONG LUMEN SINGLE 8FR
|
Facility
|
IP
|
$3,062.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.80 |
| Max. Negotiated Rate |
$2,908.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,449.60
|
| Rate for Payer: Cash Price |
$1,837.20
|
| Rate for Payer: Cash Price |
$1,837.20
|
| Rate for Payer: Cigna Commercial |
$2,602.70
|
| Rate for Payer: First Health Commercial |
$2,755.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,755.80
|
| Rate for Payer: GEHA Commercial |
$2,143.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,755.80
|
| Rate for Payer: Multiplan All |
$2,786.42
|
| Rate for Payer: OMNI Networks Commercial |
$2,143.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,755.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,908.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,296.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,847.66
|
| Rate for Payer: Zelis Auto |
$1,224.80
|
|
|
IMPLT CATHETER GROSHONG LUMEN SINGLE 8FR
|
Facility
|
OP
|
$3,062.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$765.50 |
| Max. Negotiated Rate |
$2,908.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,837.20
|
| Rate for Payer: Cash Price |
$1,837.20
|
| Rate for Payer: Cash Price |
$1,837.20
|
| Rate for Payer: Cigna Commercial |
$2,602.70
|
| Rate for Payer: First Health Commercial |
$2,755.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,755.80
|
| Rate for Payer: GEHA Commercial |
$2,449.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,755.80
|
| Rate for Payer: Humana ChoiceCare |
$796.12
|
| Rate for Payer: Multiplan All |
$2,786.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,837.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,143.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,755.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,908.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,296.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,694.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$765.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,847.66
|
| Rate for Payer: Zelis Auto |
$1,224.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,531.00
|
|
|
IMPLT CATHETER POLLACH 6 FR
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$142.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Humana ChoiceCare |
$46.28
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$106.80
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$156.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$44.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$89.00
|
|
|
IMPLT CATHETER POLLACH 6 FR
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001693
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$71.20 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$142.40
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$151.30
|
| Rate for Payer: First Health Commercial |
$160.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$160.20
|
| Rate for Payer: GEHA Commercial |
$124.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$160.20
|
| Rate for Payer: Multiplan All |
$161.98
|
| Rate for Payer: OMNI Networks Commercial |
$124.60
|
| Rate for Payer: One Health Plan PPO/POS |
$160.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$169.10
|
| Rate for Payer: Three Rivers Provider Network All |
$133.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$165.54
|
| Rate for Payer: Zelis Auto |
$71.20
|
|
|
IMPLT CATHETER TORQUEABLE ANGLED
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
7002399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.20 |
| Max. Negotiated Rate |
$264.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$222.40
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$236.30
|
| Rate for Payer: First Health Commercial |
$250.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$250.20
|
| Rate for Payer: GEHA Commercial |
$194.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$250.20
|
| Rate for Payer: Multiplan All |
$252.98
|
| Rate for Payer: OMNI Networks Commercial |
$194.60
|
| Rate for Payer: One Health Plan PPO/POS |
$250.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$264.10
|
| Rate for Payer: Three Rivers Provider Network All |
$208.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$258.54
|
| Rate for Payer: Zelis Auto |
$111.20
|
|
|
IMPLT CATHETER TORQUEABLE ANGLED
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
7002399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$69.50 |
| Max. Negotiated Rate |
$264.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$236.30
|
| Rate for Payer: First Health Commercial |
$250.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$250.20
|
| Rate for Payer: GEHA Commercial |
$222.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$250.20
|
| Rate for Payer: Humana ChoiceCare |
$72.28
|
| Rate for Payer: Multiplan All |
$252.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$166.80
|
| Rate for Payer: OMNI Networks Commercial |
$194.60
|
| Rate for Payer: One Health Plan PPO/POS |
$250.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$264.10
|
| Rate for Payer: Three Rivers Provider Network All |
$208.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$244.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$69.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$258.54
|
| Rate for Payer: Zelis Auto |
$111.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$139.00
|
|
|
IMPLT CATHETER URET 4.8FR CONE TIP
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$88.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Humana ChoiceCare |
$28.60
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$66.00
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$96.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: Zelis Auto |
$44.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$55.00
|
|
|
IMPLT CATHETER URET 4.8FR CONE TIP
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$88.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$77.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: Zelis Auto |
$44.00
|
|
|
IMPLT CATHETER URET 6 FR CONE TIP
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$88.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Humana ChoiceCare |
$28.60
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$66.00
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$96.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$27.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: Zelis Auto |
$44.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$55.00
|
|
|
IMPLT CATHETER URET 6 FR CONE TIP
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$88.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$93.50
|
| Rate for Payer: First Health Commercial |
$99.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$99.00
|
| Rate for Payer: GEHA Commercial |
$77.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$99.00
|
| Rate for Payer: Multiplan All |
$100.10
|
| Rate for Payer: OMNI Networks Commercial |
$77.00
|
| Rate for Payer: One Health Plan PPO/POS |
$99.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$104.50
|
| Rate for Payer: Three Rivers Provider Network All |
$82.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$102.30
|
| Rate for Payer: Zelis Auto |
$44.00
|
|
|
IMPLT CATHETER URETHERAL 5FR.X70CM
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$70.80 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.60
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$150.45
|
| Rate for Payer: First Health Commercial |
$159.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$159.30
|
| Rate for Payer: GEHA Commercial |
$123.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$159.30
|
| Rate for Payer: Multiplan All |
$161.07
|
| Rate for Payer: OMNI Networks Commercial |
$123.90
|
| Rate for Payer: One Health Plan PPO/POS |
$159.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$168.15
|
| Rate for Payer: Three Rivers Provider Network All |
$132.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$164.61
|
| Rate for Payer: Zelis Auto |
$70.80
|
|
|
IMPLT CATHETER URETHERAL 5FR.X70CM
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7001697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.25 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$150.45
|
| Rate for Payer: First Health Commercial |
$159.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$159.30
|
| Rate for Payer: GEHA Commercial |
$141.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$159.30
|
| Rate for Payer: Humana ChoiceCare |
$46.02
|
| Rate for Payer: Multiplan All |
$161.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$106.20
|
| Rate for Payer: OMNI Networks Commercial |
$123.90
|
| Rate for Payer: One Health Plan PPO/POS |
$159.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$168.15
|
| Rate for Payer: Three Rivers Provider Network All |
$132.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$155.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$44.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$164.61
|
| Rate for Payer: Zelis Auto |
$70.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$88.50
|
|
|
IMPLT CATH FOCAL RFA 60 BARRX
|
Facility
|
IP
|
$5,298.00
|
|
|
Service Code
|
CPT C1733
|
| Hospital Charge Code |
7006165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,119.20 |
| Max. Negotiated Rate |
$5,033.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$3,178.80
|
| Rate for Payer: Cash Price |
$3,178.80
|
| Rate for Payer: Cigna Commercial |
$4,503.30
|
| Rate for Payer: First Health Commercial |
$4,768.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,768.20
|
| Rate for Payer: GEHA Commercial |
$3,708.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,768.20
|
| Rate for Payer: Multiplan All |
$4,821.18
|
| Rate for Payer: OMNI Networks Commercial |
$3,708.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,768.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,033.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,973.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,927.14
|
| Rate for Payer: Zelis Auto |
$2,119.20
|
|
|
IMPLT CATH FOCAL RFA 60 BARRX
|
Facility
|
OP
|
$5,298.00
|
|
|
Service Code
|
CPT C1733
|
| Hospital Charge Code |
7006165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,324.50 |
| Max. Negotiated Rate |
$5,033.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,178.80
|
| Rate for Payer: Cash Price |
$3,178.80
|
| Rate for Payer: Cash Price |
$3,178.80
|
| Rate for Payer: Cigna Commercial |
$4,503.30
|
| Rate for Payer: First Health Commercial |
$4,768.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,768.20
|
| Rate for Payer: GEHA Commercial |
$4,238.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,768.20
|
| Rate for Payer: Humana ChoiceCare |
$1,377.48
|
| Rate for Payer: Multiplan All |
$4,821.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,178.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,708.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,768.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,033.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,973.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,662.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,324.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,927.14
|
| Rate for Payer: Zelis Auto |
$2,119.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,649.00
|
|
|
IMPLT CATH FOGARTY EMBOLECTOMY 3FR
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT C1757
|
| Hospital Charge Code |
7001688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.00 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$244.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$213.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
|
|
IMPLT CATH FOGARTY EMBOLECTOMY 3FR
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT C1757
|
| Hospital Charge Code |
7001688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.25 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$259.25
|
| Rate for Payer: First Health Commercial |
$274.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$274.50
|
| Rate for Payer: GEHA Commercial |
$244.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$274.50
|
| Rate for Payer: Humana ChoiceCare |
$79.30
|
| Rate for Payer: Multiplan All |
$277.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$183.00
|
| Rate for Payer: OMNI Networks Commercial |
$213.50
|
| Rate for Payer: One Health Plan PPO/POS |
$274.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$289.75
|
| Rate for Payer: Three Rivers Provider Network All |
$228.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$268.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$76.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$283.65
|
| Rate for Payer: Zelis Auto |
$122.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$152.50
|
|
