|
IMPLT GRAFT BONE VITOSS 30CC
|
Facility
|
OP
|
$7,253.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,813.25 |
| Max. Negotiated Rate |
$6,890.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,351.80
|
| Rate for Payer: Cash Price |
$4,351.80
|
| Rate for Payer: Cash Price |
$4,351.80
|
| Rate for Payer: Cigna Commercial |
$6,165.05
|
| Rate for Payer: First Health Commercial |
$6,527.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,527.70
|
| Rate for Payer: GEHA Commercial |
$5,802.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,527.70
|
| Rate for Payer: Humana ChoiceCare |
$1,885.78
|
| Rate for Payer: Multiplan All |
$6,600.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,351.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,077.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,527.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,890.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,439.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,382.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,813.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,745.29
|
| Rate for Payer: Zelis Auto |
$2,901.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,626.50
|
|
|
IMPLT GRAFT BONE VTOSS 5CC
|
Facility
|
IP
|
$7,753.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,101.20 |
| Max. Negotiated Rate |
$7,365.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,202.40
|
| Rate for Payer: Cash Price |
$4,651.80
|
| Rate for Payer: Cash Price |
$4,651.80
|
| Rate for Payer: Cigna Commercial |
$6,590.05
|
| Rate for Payer: First Health Commercial |
$6,977.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,977.70
|
| Rate for Payer: GEHA Commercial |
$5,427.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,977.70
|
| Rate for Payer: Multiplan All |
$7,055.23
|
| Rate for Payer: OMNI Networks Commercial |
$5,427.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,977.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,365.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,814.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,210.29
|
| Rate for Payer: Zelis Auto |
$3,101.20
|
|
|
IMPLT GRAFT BONE VTOSS 5CC
|
Facility
|
OP
|
$7,753.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,938.25 |
| Max. Negotiated Rate |
$7,365.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,651.80
|
| Rate for Payer: Cash Price |
$4,651.80
|
| Rate for Payer: Cash Price |
$4,651.80
|
| Rate for Payer: Cigna Commercial |
$6,590.05
|
| Rate for Payer: First Health Commercial |
$6,977.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,977.70
|
| Rate for Payer: GEHA Commercial |
$6,202.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,977.70
|
| Rate for Payer: Humana ChoiceCare |
$2,015.78
|
| Rate for Payer: Multiplan All |
$7,055.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,651.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,427.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,977.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,365.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,814.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,822.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,938.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,210.29
|
| Rate for Payer: Zelis Auto |
$3,101.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,876.50
|
|
|
IMPLT GRAFT JACKET FLOWABLE
|
Facility
|
OP
|
$6,656.00
|
|
|
Service Code
|
CPT Q4113
|
| Hospital Charge Code |
7002463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,158.25 |
| Max. Negotiated Rate |
$6,323.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$1,462.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,993.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$1,462.07
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$1,158.25
|
| Rate for Payer: Cash Price |
$3,993.60
|
| Rate for Payer: Cash Price |
$3,993.60
|
| Rate for Payer: Cash Price |
$3,993.60
|
| Rate for Payer: Cigna Commercial |
$5,657.60
|
| Rate for Payer: First Health Commercial |
$5,990.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,990.40
|
| Rate for Payer: GEHA Commercial |
$5,324.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,990.40
|
| Rate for Payer: Humana ChoiceCare |
$1,730.56
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$1,181.84
|
| Rate for Payer: Multiplan All |
$6,056.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,993.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,659.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,990.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$1,364.59
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$1,181.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,323.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,992.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,857.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,181.84
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,190.08
|
| Rate for Payer: Zelis Auto |
$2,662.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,328.00
|
|
|
IMPLT GRAFT JACKET FLOWABLE
|
Facility
|
IP
|
$6,656.00
|
|
|
Service Code
|
CPT Q4113
|
| Hospital Charge Code |
7002463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,662.40 |
| Max. Negotiated Rate |
$6,323.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,324.80
|
| Rate for Payer: Cash Price |
$3,993.60
|
| Rate for Payer: Cash Price |
$3,993.60
|
| Rate for Payer: Cigna Commercial |
$5,657.60
|
| Rate for Payer: First Health Commercial |
$5,990.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,990.40
|
| Rate for Payer: GEHA Commercial |
$4,659.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,990.40
|
| Rate for Payer: Multiplan All |
$6,056.96
|
| Rate for Payer: OMNI Networks Commercial |
$4,659.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,990.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,323.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,992.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,190.08
|
| Rate for Payer: Zelis Auto |
$2,662.40
|
|
|
IMPLT GRAFT OASIS WOUND MATRIX 7X20
|
Facility
|
IP
|
$5,921.25
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,368.50 |
| Max. Negotiated Rate |
$5,625.19 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,737.00
|
| Rate for Payer: Cash Price |
$3,552.75
|
| Rate for Payer: Cash Price |
$3,552.75
|
| Rate for Payer: Cigna Commercial |
$5,033.06
|
| Rate for Payer: First Health Commercial |
$5,329.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,329.12
|
| Rate for Payer: GEHA Commercial |
$4,144.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,329.12
|
| Rate for Payer: Multiplan All |
$5,388.34
|
| Rate for Payer: OMNI Networks Commercial |
$4,144.88
|
| Rate for Payer: One Health Plan PPO/POS |
$5,329.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,625.19
|
| Rate for Payer: Three Rivers Provider Network All |
$4,440.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,506.76
|
| Rate for Payer: Zelis Auto |
$2,368.50
|
|
|
IMPLT GRAFT OASIS WOUND MATRIX 7X20
|
Facility
|
OP
|
$5,921.25
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002460
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$5,625.19 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,552.75
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.06
|
| Rate for Payer: Cash Price |
$3,552.75
|
| Rate for Payer: Cash Price |
$3,552.75
|
| Rate for Payer: Cash Price |
$3,552.75
|
| Rate for Payer: Cigna Commercial |
$5,033.06
|
| Rate for Payer: First Health Commercial |
$5,329.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,329.12
|
| Rate for Payer: GEHA Commercial |
$13.07
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,329.12
|
| Rate for Payer: Humana ChoiceCare |
$1,539.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$13.33
|
| Rate for Payer: Multiplan All |
$5,388.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,552.75
|
| Rate for Payer: OMNI Networks Commercial |
$4,144.88
|
| Rate for Payer: One Health Plan PPO/POS |
$5,329.12
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$15.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$13.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,625.19
|
| Rate for Payer: Three Rivers Provider Network All |
$4,440.94
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,210.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,506.76
|
| Rate for Payer: Zelis Auto |
$2,368.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,960.62
|
|
|
IMPLT GRAFT PLACENTAL NOVASTEP 3X6
|
Facility
|
IP
|
$8,629.00
|
|
|
Service Code
|
CPT Q4170
|
| Hospital Charge Code |
7002515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,355.72 |
| Max. Negotiated Rate |
$8,197.55 |
| Rate for Payer: Cash Price |
$5,177.40
|
| Rate for Payer: Cigna Commercial |
$7,334.65
|
| Rate for Payer: First Health Commercial |
$7,766.10
|
| Rate for Payer: First Health Workers Compensation |
$3,331.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,766.10
|
| Rate for Payer: GEHA Commercial |
$6,040.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,766.10
|
| Rate for Payer: Multiplan All |
$7,852.39
|
| Rate for Payer: OMNI Networks Commercial |
$6,040.30
|
| Rate for Payer: One Health Plan PPO/POS |
$7,766.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,197.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6,471.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,024.97
|
| Rate for Payer: Zelis Auto |
$3,451.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2,355.72
|
|
|
IMPLT GRAFT PLACENTAL NOVASTEP 3X6
|
Facility
|
OP
|
$8,629.00
|
|
|
Service Code
|
CPT Q4170
|
| Hospital Charge Code |
7002515
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.24 |
| Max. Negotiated Rate |
$8,197.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,177.40
|
| Rate for Payer: Cash Price |
$5,177.40
|
| Rate for Payer: Cash Price |
$5,177.40
|
| Rate for Payer: Cigna Commercial |
$7,334.65
|
| Rate for Payer: First Health Commercial |
$7,766.10
|
| Rate for Payer: First Health Workers Compensation |
$3,331.66
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,766.10
|
| Rate for Payer: GEHA Commercial |
$43.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,766.10
|
| Rate for Payer: Humana ChoiceCare |
$2,243.54
|
| Rate for Payer: Multiplan All |
$7,852.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,177.40
|
| Rate for Payer: OMNI Networks Commercial |
$6,040.30
|
| Rate for Payer: One Health Plan PPO/POS |
$7,766.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,197.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6,471.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,593.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,157.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,024.97
|
| Rate for Payer: Zelis Auto |
$3,451.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,314.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2,355.72
|
|
|
IMPLT GRAFT POSTERIOR TIBIALIS
|
Facility
|
OP
|
$6,212.00
|
|
| Hospital Charge Code |
90009165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.00 |
| Max. Negotiated Rate |
$5,901.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cigna Commercial |
$5,280.20
|
| Rate for Payer: First Health Commercial |
$5,590.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,590.80
|
| Rate for Payer: GEHA Commercial |
$4,969.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,590.80
|
| Rate for Payer: Humana ChoiceCare |
$1,615.12
|
| Rate for Payer: Multiplan All |
$5,652.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,727.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,348.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,590.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,901.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,659.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,466.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,553.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,777.16
|
| Rate for Payer: Zelis Auto |
$2,484.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,106.00
|
|
|
IMPLT GRAFT POSTERIOR TIBIALIS
|
Facility
|
OP
|
$6,212.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.00 |
| Max. Negotiated Rate |
$5,901.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cigna Commercial |
$5,280.20
|
| Rate for Payer: First Health Commercial |
$5,590.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,590.80
|
| Rate for Payer: GEHA Commercial |
$4,969.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,590.80
|
| Rate for Payer: Humana ChoiceCare |
$1,615.12
|
| Rate for Payer: Multiplan All |
$5,652.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,727.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,348.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,590.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,901.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,659.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,466.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,553.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,777.16
|
| Rate for Payer: Zelis Auto |
$2,484.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,106.00
|
|
|
IMPLT GRAFT POSTERIOR TIBIALIS
|
Facility
|
IP
|
$6,212.00
|
|
| Hospital Charge Code |
90009165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,484.80 |
| Max. Negotiated Rate |
$5,901.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,969.60
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cigna Commercial |
$5,280.20
|
| Rate for Payer: First Health Commercial |
$5,590.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,590.80
|
| Rate for Payer: GEHA Commercial |
$4,348.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,590.80
|
| Rate for Payer: Multiplan All |
$5,652.92
|
| Rate for Payer: OMNI Networks Commercial |
$4,348.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,590.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,901.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,659.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,777.16
|
| Rate for Payer: Zelis Auto |
$2,484.80
|
|
|
IMPLT GRAFT POSTERIOR TIBIALIS
|
Facility
|
IP
|
$6,212.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006529
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,484.80 |
| Max. Negotiated Rate |
$5,901.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,969.60
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cash Price |
$3,727.20
|
| Rate for Payer: Cigna Commercial |
$5,280.20
|
| Rate for Payer: First Health Commercial |
$5,590.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,590.80
|
| Rate for Payer: GEHA Commercial |
$4,348.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,590.80
|
| Rate for Payer: Multiplan All |
$5,652.92
|
| Rate for Payer: OMNI Networks Commercial |
$4,348.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,590.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,901.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,659.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,777.16
|
| Rate for Payer: Zelis Auto |
$2,484.80
|
|
|
IMPLT GRAFT XENMATRIX 3.9X5.9
|
Facility
|
OP
|
$13,294.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,323.50 |
| Max. Negotiated Rate |
$12,629.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,976.40
|
| Rate for Payer: Cash Price |
$7,976.40
|
| Rate for Payer: Cash Price |
$7,976.40
|
| Rate for Payer: Cigna Commercial |
$11,299.90
|
| Rate for Payer: First Health Commercial |
$11,964.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,964.60
|
| Rate for Payer: GEHA Commercial |
$10,635.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,964.60
|
| Rate for Payer: Humana ChoiceCare |
$3,456.44
|
| Rate for Payer: Multiplan All |
$12,097.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,976.40
|
| Rate for Payer: OMNI Networks Commercial |
$9,305.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,964.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,629.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,970.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,698.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,323.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,363.42
|
| Rate for Payer: Zelis Auto |
$5,317.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,647.00
|
|
|
IMPLT GRAFT XENMATRIX 3.9X5.9
|
Facility
|
IP
|
$13,294.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,317.60 |
| Max. Negotiated Rate |
$12,629.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,635.20
|
| Rate for Payer: Cash Price |
$7,976.40
|
| Rate for Payer: Cash Price |
$7,976.40
|
| Rate for Payer: Cigna Commercial |
$11,299.90
|
| Rate for Payer: First Health Commercial |
$11,964.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,964.60
|
| Rate for Payer: GEHA Commercial |
$9,305.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,964.60
|
| Rate for Payer: Multiplan All |
$12,097.54
|
| Rate for Payer: OMNI Networks Commercial |
$9,305.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,964.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,629.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,970.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$12,363.42
|
| Rate for Payer: Zelis Auto |
$5,317.60
|
|
|
IMPLT GRAFT XENMATRIX 6X6
|
Facility
|
OP
|
$3,625.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$906.25 |
| Max. Negotiated Rate |
$3,443.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,175.00
|
| Rate for Payer: Cash Price |
$2,175.00
|
| Rate for Payer: Cash Price |
$2,175.00
|
| Rate for Payer: Cigna Commercial |
$3,081.25
|
| Rate for Payer: First Health Commercial |
$3,262.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,262.50
|
| Rate for Payer: GEHA Commercial |
$2,900.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,262.50
|
| Rate for Payer: Humana ChoiceCare |
$942.50
|
| Rate for Payer: Multiplan All |
$3,298.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,175.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,537.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,262.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,443.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,718.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,190.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$906.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,371.25
|
| Rate for Payer: Zelis Auto |
$1,450.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,812.50
|
|
|
IMPLT GRAFT XENMATRIX 6X6
|
Facility
|
IP
|
$3,625.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7006532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.00 |
| Max. Negotiated Rate |
$3,443.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,900.00
|
| Rate for Payer: Cash Price |
$2,175.00
|
| Rate for Payer: Cash Price |
$2,175.00
|
| Rate for Payer: Cigna Commercial |
$3,081.25
|
| Rate for Payer: First Health Commercial |
$3,262.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,262.50
|
| Rate for Payer: GEHA Commercial |
$2,537.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,262.50
|
| Rate for Payer: Multiplan All |
$3,298.75
|
| Rate for Payer: OMNI Networks Commercial |
$2,537.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,262.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,443.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,718.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,371.25
|
| Rate for Payer: Zelis Auto |
$1,450.00
|
|
|
IMPLT GRAFT XENMATRIX AB 19CM X 35CM
|
Facility
|
OP
|
$57,018.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002328
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,254.50 |
| Max. Negotiated Rate |
$54,167.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$34,210.80
|
| Rate for Payer: Cash Price |
$34,210.80
|
| Rate for Payer: Cash Price |
$34,210.80
|
| Rate for Payer: Cigna Commercial |
$48,465.30
|
| Rate for Payer: First Health Commercial |
$51,316.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51,316.20
|
| Rate for Payer: GEHA Commercial |
$45,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51,316.20
|
| Rate for Payer: Humana ChoiceCare |
$14,824.68
|
| Rate for Payer: Multiplan All |
$51,886.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$34,210.80
|
| Rate for Payer: OMNI Networks Commercial |
$39,912.60
|
| Rate for Payer: One Health Plan PPO/POS |
$51,316.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54,167.10
|
| Rate for Payer: Three Rivers Provider Network All |
$42,763.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$50,175.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$14,254.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53,026.74
|
| Rate for Payer: Zelis Auto |
$22,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$28,509.00
|
|
|
IMPLT GRAFT XENMATRIX AB 19CM X 35CM
|
Facility
|
IP
|
$57,018.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002328
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,807.20 |
| Max. Negotiated Rate |
$54,167.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45,614.40
|
| Rate for Payer: Cash Price |
$34,210.80
|
| Rate for Payer: Cash Price |
$34,210.80
|
| Rate for Payer: Cigna Commercial |
$48,465.30
|
| Rate for Payer: First Health Commercial |
$51,316.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$51,316.20
|
| Rate for Payer: GEHA Commercial |
$39,912.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$51,316.20
|
| Rate for Payer: Multiplan All |
$51,886.38
|
| Rate for Payer: OMNI Networks Commercial |
$39,912.60
|
| Rate for Payer: One Health Plan PPO/POS |
$51,316.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$54,167.10
|
| Rate for Payer: Three Rivers Provider Network All |
$42,763.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$53,026.74
|
| Rate for Payer: Zelis Auto |
$22,807.20
|
|
|
IMPLT GREENFIELD FEMORAL
|
Facility
|
OP
|
$4,412.00
|
|
|
Service Code
|
CPT C1880
|
| Hospital Charge Code |
7002396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.00 |
| Max. Negotiated Rate |
$4,191.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cigna Commercial |
$3,750.20
|
| Rate for Payer: First Health Commercial |
$3,970.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,970.80
|
| Rate for Payer: GEHA Commercial |
$3,529.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,970.80
|
| Rate for Payer: Humana ChoiceCare |
$1,147.12
|
| Rate for Payer: Multiplan All |
$4,014.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,647.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,088.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,970.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,191.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,309.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,882.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,103.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,103.16
|
| Rate for Payer: Zelis Auto |
$1,764.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,206.00
|
|
|
IMPLT GREENFIELD FEMORAL
|
Facility
|
IP
|
$4,412.00
|
|
|
Service Code
|
CPT C1880
|
| Hospital Charge Code |
7002396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,764.80 |
| Max. Negotiated Rate |
$4,191.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,529.60
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cigna Commercial |
$3,750.20
|
| Rate for Payer: First Health Commercial |
$3,970.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,970.80
|
| Rate for Payer: GEHA Commercial |
$3,088.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,970.80
|
| Rate for Payer: Multiplan All |
$4,014.92
|
| Rate for Payer: OMNI Networks Commercial |
$3,088.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,970.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,191.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,309.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,103.16
|
| Rate for Payer: Zelis Auto |
$1,764.80
|
|
|
IMPLT GREENFIELD JUGULAR 12FR
|
Facility
|
OP
|
$4,412.00
|
|
|
Service Code
|
CPT C1880
|
| Hospital Charge Code |
7002397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.00 |
| Max. Negotiated Rate |
$4,191.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cigna Commercial |
$3,750.20
|
| Rate for Payer: First Health Commercial |
$3,970.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,970.80
|
| Rate for Payer: GEHA Commercial |
$3,529.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,970.80
|
| Rate for Payer: Humana ChoiceCare |
$1,147.12
|
| Rate for Payer: Multiplan All |
$4,014.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,647.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,088.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,970.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,191.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,309.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,882.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,103.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,103.16
|
| Rate for Payer: Zelis Auto |
$1,764.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,206.00
|
|
|
IMPLT GREENFIELD JUGULAR 12FR
|
Facility
|
IP
|
$4,412.00
|
|
|
Service Code
|
CPT C1880
|
| Hospital Charge Code |
7002397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,764.80 |
| Max. Negotiated Rate |
$4,191.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,529.60
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cash Price |
$2,647.20
|
| Rate for Payer: Cigna Commercial |
$3,750.20
|
| Rate for Payer: First Health Commercial |
$3,970.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,970.80
|
| Rate for Payer: GEHA Commercial |
$3,088.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,970.80
|
| Rate for Payer: Multiplan All |
$4,014.92
|
| Rate for Payer: OMNI Networks Commercial |
$3,088.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,970.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,191.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,309.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,103.16
|
| Rate for Payer: Zelis Auto |
$1,764.80
|
|
|
IMPLT GREEN LINEAR CUTTER RELOAD
|
Facility
|
IP
|
$823.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7007061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$329.20 |
| Max. Negotiated Rate |
$781.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$658.40
|
| Rate for Payer: Cash Price |
$493.80
|
| Rate for Payer: Cash Price |
$493.80
|
| Rate for Payer: Cigna Commercial |
$699.55
|
| Rate for Payer: First Health Commercial |
$740.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$740.70
|
| Rate for Payer: GEHA Commercial |
$576.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$740.70
|
| Rate for Payer: Multiplan All |
$748.93
|
| Rate for Payer: OMNI Networks Commercial |
$576.10
|
| Rate for Payer: One Health Plan PPO/POS |
$740.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$781.85
|
| Rate for Payer: Three Rivers Provider Network All |
$617.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$765.39
|
| Rate for Payer: Zelis Auto |
$329.20
|
|
|
IMPLT GREEN LINEAR CUTTER RELOAD
|
Facility
|
OP
|
$823.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7007061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$205.75 |
| Max. Negotiated Rate |
$781.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$493.80
|
| Rate for Payer: Cash Price |
$493.80
|
| Rate for Payer: Cash Price |
$493.80
|
| Rate for Payer: Cigna Commercial |
$699.55
|
| Rate for Payer: First Health Commercial |
$740.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$740.70
|
| Rate for Payer: GEHA Commercial |
$658.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$740.70
|
| Rate for Payer: Humana ChoiceCare |
$213.98
|
| Rate for Payer: Multiplan All |
$748.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$493.80
|
| Rate for Payer: OMNI Networks Commercial |
$576.10
|
| Rate for Payer: One Health Plan PPO/POS |
$740.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$781.85
|
| Rate for Payer: Three Rivers Provider Network All |
$617.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$724.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$205.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$765.39
|
| Rate for Payer: Zelis Auto |
$329.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$411.50
|
|
