|
IMPLT INSERT POLYETHYLENE 10 DEGREE
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT POLYETHYLENE 10 DEGREE
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT POLYETHYLENE 28MM D
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT POLYETHYLENE 28MM D
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT POLYETHYLENE 32MM D
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT POLYETHYLENE 32MM D
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT POLYETHYLENE 36MM
|
Facility
|
IP
|
$3,565.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006411
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,426.00 |
| Max. Negotiated Rate |
$3,386.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,852.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cigna Commercial |
$3,030.25
|
| Rate for Payer: First Health Commercial |
$3,208.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,208.50
|
| Rate for Payer: GEHA Commercial |
$2,495.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,208.50
|
| Rate for Payer: Multiplan All |
$3,244.15
|
| Rate for Payer: OMNI Networks Commercial |
$2,495.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,208.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,386.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,673.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,315.45
|
| Rate for Payer: Zelis Auto |
$1,426.00
|
|
|
IMPLT INSERT POLYETHYLENE 36MM
|
Facility
|
IP
|
$3,565.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,426.00 |
| Max. Negotiated Rate |
$3,386.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,852.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cigna Commercial |
$3,030.25
|
| Rate for Payer: First Health Commercial |
$3,208.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,208.50
|
| Rate for Payer: GEHA Commercial |
$2,495.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,208.50
|
| Rate for Payer: Multiplan All |
$3,244.15
|
| Rate for Payer: OMNI Networks Commercial |
$2,495.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,208.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,386.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,673.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,315.45
|
| Rate for Payer: Zelis Auto |
$1,426.00
|
|
|
IMPLT INSERT POLYETHYLENE 36MM
|
Facility
|
OP
|
$3,565.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$891.25 |
| Max. Negotiated Rate |
$3,386.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cigna Commercial |
$3,030.25
|
| Rate for Payer: First Health Commercial |
$3,208.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,208.50
|
| Rate for Payer: GEHA Commercial |
$2,852.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,208.50
|
| Rate for Payer: Humana ChoiceCare |
$926.90
|
| Rate for Payer: Multiplan All |
$3,244.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,139.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,495.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,208.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,386.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,673.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,137.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$891.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,315.45
|
| Rate for Payer: Zelis Auto |
$1,426.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,782.50
|
|
|
IMPLT INSERT POLYETHYLENE 36MM
|
Facility
|
OP
|
$3,565.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006411
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$891.25 |
| Max. Negotiated Rate |
$3,386.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cash Price |
$2,139.00
|
| Rate for Payer: Cigna Commercial |
$3,030.25
|
| Rate for Payer: First Health Commercial |
$3,208.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,208.50
|
| Rate for Payer: GEHA Commercial |
$2,852.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,208.50
|
| Rate for Payer: Humana ChoiceCare |
$926.90
|
| Rate for Payer: Multiplan All |
$3,244.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,139.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,495.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,208.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,386.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,673.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,137.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$891.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,315.45
|
| Rate for Payer: Zelis Auto |
$1,426.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,782.50
|
|
|
IMPLT INSERT POLYETHYLENE 36MM E
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT POLYETHYLENE 36MM E
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT POLYETHYLENE DEGREE 10
|
Facility
|
OP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$944.00 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$3,020.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Humana ChoiceCare |
$981.76
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,265.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,322.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$944.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,888.00
|
|
|
IMPLT INSERT POLYETHYLENE DEGREE 10
|
Facility
|
IP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.40 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,020.80
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$2,643.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
|
|
IMPLT INSERT POLYTHYLENE 0 DEGREE
|
Facility
|
IP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.40 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,020.80
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$2,643.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
|
|
IMPLT INSERT POLYTHYLENE 0 DEGREE
|
Facility
|
OP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$944.00 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$3,020.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Humana ChoiceCare |
$981.76
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,265.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,322.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$944.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,888.00
|
|
|
IMPLT INSERT POLYTHYLENE 36MM 10DEG.
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002047
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT POLYTHYLENE 36MM 10DEG.
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002047
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT RESTORATION 22.2 36C
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
|
IMPLT INSERT RESTORATION 22.2 36C
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.50 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Humana ChoiceCare |
$930.28
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,146.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,148.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$894.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,789.00
|
|
|
IMPLT INSERT RESTORATION 22.2 38D
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.50 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Humana ChoiceCare |
$930.28
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,146.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,148.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$894.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,789.00
|
|
|
IMPLT INSERT RESTORATION 22.2 38D
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
|
IMPLT INSERT RESTORATION SIZE 42E
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
|
IMPLT INSERT RESTORATION SIZE 42E
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002048
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.50 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Humana ChoiceCare |
$930.28
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,146.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,148.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$894.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,789.00
|
|
|
IMPLT INSERT RESTORATION X3 42E 28/48
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
