|
IMPLT GRIP LG 2-CAB TROCHANTER
|
Facility
|
IP
|
$4,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000223
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,840.00 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,680.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cigna Commercial |
$3,910.00
|
| Rate for Payer: First Health Commercial |
$4,140.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,140.00
|
| Rate for Payer: GEHA Commercial |
$3,220.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,140.00
|
| Rate for Payer: Multiplan All |
$4,186.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,220.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,140.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,370.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,450.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,278.00
|
| Rate for Payer: Zelis Auto |
$1,840.00
|
|
|
IMPLT GRIP LG 2-CAB TROCHANTER
|
Facility
|
OP
|
$4,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000223
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.00 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cigna Commercial |
$3,910.00
|
| Rate for Payer: First Health Commercial |
$4,140.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,140.00
|
| Rate for Payer: GEHA Commercial |
$3,680.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,140.00
|
| Rate for Payer: Humana ChoiceCare |
$1,196.00
|
| Rate for Payer: Multiplan All |
$4,186.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,760.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,220.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,140.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,370.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,450.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,048.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,150.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,278.00
|
| Rate for Payer: Zelis Auto |
$1,840.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,300.00
|
|
|
IMPLT GRIP MD 2-CAB TROCHANTER
|
Facility
|
OP
|
$5,162.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000222
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,290.50 |
| Max. Negotiated Rate |
$4,903.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,097.20
|
| Rate for Payer: Cash Price |
$3,097.20
|
| Rate for Payer: Cash Price |
$3,097.20
|
| Rate for Payer: Cigna Commercial |
$4,387.70
|
| Rate for Payer: First Health Commercial |
$4,645.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,645.80
|
| Rate for Payer: GEHA Commercial |
$4,129.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,645.80
|
| Rate for Payer: Humana ChoiceCare |
$1,342.12
|
| Rate for Payer: Multiplan All |
$4,697.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,097.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,613.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,645.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,903.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,871.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,542.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,290.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,800.66
|
| Rate for Payer: Zelis Auto |
$2,064.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,581.00
|
|
|
IMPLT GRIP MD 2-CAB TROCHANTER
|
Facility
|
IP
|
$5,162.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000222
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,064.80 |
| Max. Negotiated Rate |
$4,903.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,129.60
|
| Rate for Payer: Cash Price |
$3,097.20
|
| Rate for Payer: Cash Price |
$3,097.20
|
| Rate for Payer: Cigna Commercial |
$4,387.70
|
| Rate for Payer: First Health Commercial |
$4,645.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,645.80
|
| Rate for Payer: GEHA Commercial |
$3,613.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,645.80
|
| Rate for Payer: Multiplan All |
$4,697.42
|
| Rate for Payer: OMNI Networks Commercial |
$3,613.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,645.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,903.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,871.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,800.66
|
| Rate for Payer: Zelis Auto |
$2,064.80
|
|
|
IMPLT GRIP SM 2-CAB TROCHANTER
|
Facility
|
IP
|
$4,029.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,611.60 |
| Max. Negotiated Rate |
$3,827.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,223.20
|
| Rate for Payer: Cash Price |
$2,417.40
|
| Rate for Payer: Cash Price |
$2,417.40
|
| Rate for Payer: Cigna Commercial |
$3,424.65
|
| Rate for Payer: First Health Commercial |
$3,626.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,626.10
|
| Rate for Payer: GEHA Commercial |
$2,820.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,626.10
|
| Rate for Payer: Multiplan All |
$3,666.39
|
| Rate for Payer: OMNI Networks Commercial |
$2,820.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,626.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,827.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,021.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,746.97
|
| Rate for Payer: Zelis Auto |
$1,611.60
|
|
|
IMPLT GRIP SM 2-CAB TROCHANTER
|
Facility
|
OP
|
$4,029.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,007.25 |
| Max. Negotiated Rate |
$3,827.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,417.40
|
| Rate for Payer: Cash Price |
$2,417.40
|
| Rate for Payer: Cash Price |
$2,417.40
|
| Rate for Payer: Cigna Commercial |
$3,424.65
|
| Rate for Payer: First Health Commercial |
$3,626.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,626.10
|
| Rate for Payer: GEHA Commercial |
$3,223.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,626.10
|
| Rate for Payer: Humana ChoiceCare |
$1,047.54
|
| Rate for Payer: Multiplan All |
$3,666.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,417.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,820.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,626.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,827.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,021.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,545.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,007.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,746.97
|
| Rate for Payer: Zelis Auto |
$1,611.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,014.50
|
|
|
IMPLT GRIP SM TROCHANTER STAINLESS
|
Facility
|
IP
|
$4,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,840.00 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,680.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cigna Commercial |
$3,910.00
|
| Rate for Payer: First Health Commercial |
$4,140.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,140.00
|
| Rate for Payer: GEHA Commercial |
$3,220.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,140.00
|
| Rate for Payer: Multiplan All |
$4,186.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,220.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,140.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,370.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,450.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,278.00
|
| Rate for Payer: Zelis Auto |
$1,840.00
|
|
|
IMPLT GRIP SM TROCHANTER STAINLESS
|
Facility
|
OP
|
$4,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.00 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cash Price |
$2,760.00
|
| Rate for Payer: Cigna Commercial |
$3,910.00
|
| Rate for Payer: First Health Commercial |
$4,140.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,140.00
|
| Rate for Payer: GEHA Commercial |
$3,680.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,140.00
|
| Rate for Payer: Humana ChoiceCare |
$1,196.00
|
| Rate for Payer: Multiplan All |
$4,186.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,760.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,220.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,140.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,370.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,450.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,048.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,150.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,278.00
|
| Rate for Payer: Zelis Auto |
$1,840.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,300.00
|
|
|
IMPLT GROSHONG CONNECTOR REPLACEMENT
|
Facility
|
OP
|
$914.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7001681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$731.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Humana ChoiceCare |
$237.64
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$548.40
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$804.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$228.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$457.00
|
|
|
IMPLT GROSHONG CONNECTOR REPLACEMENT
|
Facility
|
IP
|
$914.00
|
|
|
Service Code
|
CPT C1751
|
| Hospital Charge Code |
7001681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$365.60 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$731.20
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$639.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
|
|
IMPLT GROSHONG KIT CATH REPAIR
|
Facility
|
OP
|
$1,078.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$269.50 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Humana ChoiceCare |
$280.28
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$646.80
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$948.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$269.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$539.00
|
|
|
IMPLT GROSHONG KIT CATH REPAIR
|
Facility
|
IP
|
$1,078.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$431.20 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$862.40
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$754.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
|
|
IMPLT GUIDE PIN 1.0MM 70MM 6/PK
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000225
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$252.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$212.80
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$226.10
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$239.40
|
| Rate for Payer: GEHA Commercial |
$186.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$239.40
|
| Rate for Payer: Multiplan All |
$242.06
|
| Rate for Payer: OMNI Networks Commercial |
$186.20
|
| Rate for Payer: One Health Plan PPO/POS |
$239.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$252.70
|
| Rate for Payer: Three Rivers Provider Network All |
$199.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$247.38
|
| Rate for Payer: Zelis Auto |
$106.40
|
|
|
IMPLT GUIDE PIN 1.0MM 70MM 6/PK
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000225
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$252.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$226.10
|
| Rate for Payer: First Health Commercial |
$239.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$239.40
|
| Rate for Payer: GEHA Commercial |
$212.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$239.40
|
| Rate for Payer: Humana ChoiceCare |
$69.16
|
| Rate for Payer: Multiplan All |
$242.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$159.60
|
| Rate for Payer: OMNI Networks Commercial |
$186.20
|
| Rate for Payer: One Health Plan PPO/POS |
$239.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$252.70
|
| Rate for Payer: Three Rivers Provider Network All |
$199.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$234.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$66.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$247.38
|
| Rate for Payer: Zelis Auto |
$106.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$133.00
|
|
|
IMPLT GUIDEWIRE .018 MPIS-505-U-SST
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$51.75 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$175.95
|
| Rate for Payer: First Health Commercial |
$186.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$186.30
|
| Rate for Payer: GEHA Commercial |
$165.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$186.30
|
| Rate for Payer: Humana ChoiceCare |
$53.82
|
| Rate for Payer: Multiplan All |
$188.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$124.20
|
| Rate for Payer: OMNI Networks Commercial |
$144.90
|
| Rate for Payer: One Health Plan PPO/POS |
$186.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$196.65
|
| Rate for Payer: Three Rivers Provider Network All |
$155.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$182.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$192.51
|
| Rate for Payer: Zelis Auto |
$82.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$103.50
|
|
|
IMPLT GUIDEWIRE .018 MPIS-505-U-SST
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$82.80 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$165.60
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$175.95
|
| Rate for Payer: First Health Commercial |
$186.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$186.30
|
| Rate for Payer: GEHA Commercial |
$144.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$186.30
|
| Rate for Payer: Multiplan All |
$188.37
|
| Rate for Payer: OMNI Networks Commercial |
$144.90
|
| Rate for Payer: One Health Plan PPO/POS |
$186.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$196.65
|
| Rate for Payer: Three Rivers Provider Network All |
$155.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$192.51
|
| Rate for Payer: Zelis Auto |
$82.80
|
|
|
IMPLT GUIDEWIRE .025" 80CM LENGTH 5M/O
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$54.40 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$108.80
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$115.60
|
| Rate for Payer: First Health Commercial |
$122.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$122.40
|
| Rate for Payer: GEHA Commercial |
$95.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$122.40
|
| Rate for Payer: Multiplan All |
$123.76
|
| Rate for Payer: OMNI Networks Commercial |
$95.20
|
| Rate for Payer: One Health Plan PPO/POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$129.20
|
| Rate for Payer: Three Rivers Provider Network All |
$102.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$126.48
|
| Rate for Payer: Zelis Auto |
$54.40
|
|
|
IMPLT GUIDEWIRE .025" 80CM LENGTH 5M/O
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$115.60
|
| Rate for Payer: First Health Commercial |
$122.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$122.40
|
| Rate for Payer: GEHA Commercial |
$108.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$122.40
|
| Rate for Payer: Humana ChoiceCare |
$35.36
|
| Rate for Payer: Multiplan All |
$123.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$81.60
|
| Rate for Payer: OMNI Networks Commercial |
$95.20
|
| Rate for Payer: One Health Plan PPO/POS |
$122.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$129.20
|
| Rate for Payer: Three Rivers Provider Network All |
$102.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$119.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$34.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$126.48
|
| Rate for Payer: Zelis Auto |
$54.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$68.00
|
|
|
IMPLT GUIDEWIRE .035 INCH 80CM LENGTH
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$60.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Humana ChoiceCare |
$19.76
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$45.60
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$66.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$19.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$38.00
|
|
|
IMPLT GUIDEWIRE .035 INCH 80CM LENGTH
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.80
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$64.60
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$68.40
|
| Rate for Payer: GEHA Commercial |
$53.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$68.40
|
| Rate for Payer: Multiplan All |
$69.16
|
| Rate for Payer: OMNI Networks Commercial |
$53.20
|
| Rate for Payer: One Health Plan PPO/POS |
$68.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$72.20
|
| Rate for Payer: Three Rivers Provider Network All |
$57.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$70.68
|
| Rate for Payer: Zelis Auto |
$30.40
|
|
|
IMPLT GUIDEWIRE .035X5.75 STRAIGHT
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.80 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$113.60
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cigna Commercial |
$120.70
|
| Rate for Payer: First Health Commercial |
$127.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$127.80
|
| Rate for Payer: GEHA Commercial |
$99.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$127.80
|
| Rate for Payer: Multiplan All |
$129.22
|
| Rate for Payer: OMNI Networks Commercial |
$99.40
|
| Rate for Payer: One Health Plan PPO/POS |
$127.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$134.90
|
| Rate for Payer: Three Rivers Provider Network All |
$106.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$132.06
|
| Rate for Payer: Zelis Auto |
$56.80
|
|
|
IMPLT GUIDEWIRE .035X5.75 STRAIGHT
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$35.50 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$85.20
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cigna Commercial |
$120.70
|
| Rate for Payer: First Health Commercial |
$127.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$127.80
|
| Rate for Payer: GEHA Commercial |
$113.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$127.80
|
| Rate for Payer: Humana ChoiceCare |
$36.92
|
| Rate for Payer: Multiplan All |
$129.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$85.20
|
| Rate for Payer: OMNI Networks Commercial |
$99.40
|
| Rate for Payer: One Health Plan PPO/POS |
$127.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$134.90
|
| Rate for Payer: Three Rivers Provider Network All |
$106.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$124.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$35.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$132.06
|
| Rate for Payer: Zelis Auto |
$56.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$71.00
|
|
|
IMPLT GUIDE WIRE 0.38 MM ZIMMER
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38.75 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$124.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$40.30
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$93.00
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$136.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$38.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$77.50
|
|
|
IMPLT GUIDE WIRE 0.38 MM ZIMMER
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$147.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$124.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$131.75
|
| Rate for Payer: First Health Commercial |
$139.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$139.50
|
| Rate for Payer: GEHA Commercial |
$108.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$139.50
|
| Rate for Payer: Multiplan All |
$141.05
|
| Rate for Payer: OMNI Networks Commercial |
$108.50
|
| Rate for Payer: One Health Plan PPO/POS |
$139.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$147.25
|
| Rate for Payer: Three Rivers Provider Network All |
$116.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$144.15
|
| Rate for Payer: Zelis Auto |
$62.00
|
|
|
IMPLT GUIDEWIRE .038 PTFE FLEXIBLE
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
7001722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$45.20 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$90.40
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$96.05
|
| Rate for Payer: First Health Commercial |
$101.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$101.70
|
| Rate for Payer: GEHA Commercial |
$79.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$101.70
|
| Rate for Payer: Multiplan All |
$102.83
|
| Rate for Payer: OMNI Networks Commercial |
$79.10
|
| Rate for Payer: One Health Plan PPO/POS |
$101.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$107.35
|
| Rate for Payer: Three Rivers Provider Network All |
$84.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$105.09
|
| Rate for Payer: Zelis Auto |
$45.20
|
|
