|
IMPLT MESH OVAL 6X8
|
Facility
|
OP
|
$4,295.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002910
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.75 |
| Max. Negotiated Rate |
$4,080.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,577.00
|
| Rate for Payer: Cash Price |
$2,577.00
|
| Rate for Payer: Cash Price |
$2,577.00
|
| Rate for Payer: Cigna Commercial |
$3,650.75
|
| Rate for Payer: First Health Commercial |
$3,865.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,865.50
|
| Rate for Payer: GEHA Commercial |
$3,436.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,865.50
|
| Rate for Payer: Humana ChoiceCare |
$1,116.70
|
| Rate for Payer: Multiplan All |
$3,908.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,577.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,006.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,865.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,080.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,221.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,779.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,073.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,994.35
|
| Rate for Payer: Zelis Auto |
$1,718.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,147.50
|
|
|
IMPLT MESH PERFIX PLUG LIGHT LARGE
|
Facility
|
IP
|
$968.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$387.20 |
| Max. Negotiated Rate |
$919.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$774.40
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cigna Commercial |
$822.80
|
| Rate for Payer: First Health Commercial |
$871.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$871.20
|
| Rate for Payer: GEHA Commercial |
$677.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$871.20
|
| Rate for Payer: Multiplan All |
$880.88
|
| Rate for Payer: OMNI Networks Commercial |
$677.60
|
| Rate for Payer: One Health Plan PPO/POS |
$871.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$919.60
|
| Rate for Payer: Three Rivers Provider Network All |
$726.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$900.24
|
| Rate for Payer: Zelis Auto |
$387.20
|
|
|
IMPLT MESH PERFIX PLUG LIGHT LARGE
|
Facility
|
OP
|
$968.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$242.00 |
| Max. Negotiated Rate |
$919.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$580.80
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cigna Commercial |
$822.80
|
| Rate for Payer: First Health Commercial |
$871.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$871.20
|
| Rate for Payer: GEHA Commercial |
$774.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$871.20
|
| Rate for Payer: Humana ChoiceCare |
$251.68
|
| Rate for Payer: Multiplan All |
$880.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$580.80
|
| Rate for Payer: OMNI Networks Commercial |
$677.60
|
| Rate for Payer: One Health Plan PPO/POS |
$871.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$919.60
|
| Rate for Payer: Three Rivers Provider Network All |
$726.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$851.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$242.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$900.24
|
| Rate for Payer: Zelis Auto |
$387.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$484.00
|
|
|
IMPLT MESH PERFIX PLUG LIGHT MEDIUM
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$576.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$816.00
|
| Rate for Payer: First Health Commercial |
$864.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$864.00
|
| Rate for Payer: GEHA Commercial |
$768.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$864.00
|
| Rate for Payer: Humana ChoiceCare |
$249.60
|
| Rate for Payer: Multiplan All |
$873.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$576.00
|
| Rate for Payer: OMNI Networks Commercial |
$672.00
|
| Rate for Payer: One Health Plan PPO/POS |
$864.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$912.00
|
| Rate for Payer: Three Rivers Provider Network All |
$720.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$844.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$240.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$892.80
|
| Rate for Payer: Zelis Auto |
$384.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$480.00
|
|
|
IMPLT MESH PERFIX PLUG LIGHT MEDIUM
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.00 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$768.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$816.00
|
| Rate for Payer: First Health Commercial |
$864.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$864.00
|
| Rate for Payer: GEHA Commercial |
$672.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$864.00
|
| Rate for Payer: Multiplan All |
$873.60
|
| Rate for Payer: OMNI Networks Commercial |
$672.00
|
| Rate for Payer: One Health Plan PPO/POS |
$864.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$912.00
|
| Rate for Payer: Three Rivers Provider Network All |
$720.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$892.80
|
| Rate for Payer: Zelis Auto |
$384.00
|
|
|
IMPLT MESH PERFIX PLUG LIGHT X-LARGE
|
Facility
|
OP
|
$1,085.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$271.25 |
| Max. Negotiated Rate |
$1,030.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$651.00
|
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Cigna Commercial |
$922.25
|
| Rate for Payer: First Health Commercial |
$976.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$976.50
|
| Rate for Payer: GEHA Commercial |
$868.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$976.50
|
| Rate for Payer: Humana ChoiceCare |
$282.10
|
| Rate for Payer: Multiplan All |
$987.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$651.00
|
| Rate for Payer: OMNI Networks Commercial |
$759.50
|
| Rate for Payer: One Health Plan PPO/POS |
$976.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,030.75
|
| Rate for Payer: Three Rivers Provider Network All |
$813.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$954.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$271.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,009.05
|
| Rate for Payer: Zelis Auto |
$434.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$542.50
|
|
|
IMPLT MESH PERFIX PLUG LIGHT X-LARGE
|
Facility
|
IP
|
$1,085.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$1,030.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$868.00
|
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Cigna Commercial |
$922.25
|
| Rate for Payer: First Health Commercial |
$976.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$976.50
|
| Rate for Payer: GEHA Commercial |
$759.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$976.50
|
| Rate for Payer: Multiplan All |
$987.35
|
| Rate for Payer: OMNI Networks Commercial |
$759.50
|
| Rate for Payer: One Health Plan PPO/POS |
$976.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,030.75
|
| Rate for Payer: Three Rivers Provider Network All |
$813.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,009.05
|
| Rate for Payer: Zelis Auto |
$434.00
|
|
|
IMPLT MESH PERMAFIX 30 PERMANENT
|
Facility
|
IP
|
$2,287.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$914.80 |
| Max. Negotiated Rate |
$2,172.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,829.60
|
| Rate for Payer: Cash Price |
$1,372.20
|
| Rate for Payer: Cash Price |
$1,372.20
|
| Rate for Payer: Cigna Commercial |
$1,943.95
|
| Rate for Payer: First Health Commercial |
$2,058.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,058.30
|
| Rate for Payer: GEHA Commercial |
$1,600.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,058.30
|
| Rate for Payer: Multiplan All |
$2,081.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,600.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,058.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,172.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,715.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,126.91
|
| Rate for Payer: Zelis Auto |
$914.80
|
|
|
IMPLT MESH PERMAFIX 30 PERMANENT
|
Facility
|
OP
|
$2,287.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$571.75 |
| Max. Negotiated Rate |
$2,172.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,372.20
|
| Rate for Payer: Cash Price |
$1,372.20
|
| Rate for Payer: Cash Price |
$1,372.20
|
| Rate for Payer: Cigna Commercial |
$1,943.95
|
| Rate for Payer: First Health Commercial |
$2,058.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,058.30
|
| Rate for Payer: GEHA Commercial |
$1,829.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,058.30
|
| Rate for Payer: Humana ChoiceCare |
$594.62
|
| Rate for Payer: Multiplan All |
$2,081.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,372.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,600.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,058.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,172.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,715.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,012.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$571.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,126.91
|
| Rate for Payer: Zelis Auto |
$914.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,143.50
|
|
|
IMPLT MESH PLUG PERFIX LIGHT SMALL
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$382.00 |
| Max. Negotiated Rate |
$907.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$764.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$811.75
|
| Rate for Payer: First Health Commercial |
$859.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$859.50
|
| Rate for Payer: GEHA Commercial |
$668.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$859.50
|
| Rate for Payer: Multiplan All |
$869.05
|
| Rate for Payer: OMNI Networks Commercial |
$668.50
|
| Rate for Payer: One Health Plan PPO/POS |
$859.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$907.25
|
| Rate for Payer: Three Rivers Provider Network All |
$716.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$888.15
|
| Rate for Payer: Zelis Auto |
$382.00
|
|
|
IMPLT MESH PLUG PERFIX LIGHT SMALL
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$238.75 |
| Max. Negotiated Rate |
$907.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$811.75
|
| Rate for Payer: First Health Commercial |
$859.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$859.50
|
| Rate for Payer: GEHA Commercial |
$764.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$859.50
|
| Rate for Payer: Humana ChoiceCare |
$248.30
|
| Rate for Payer: Multiplan All |
$869.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$573.00
|
| Rate for Payer: OMNI Networks Commercial |
$668.50
|
| Rate for Payer: One Health Plan PPO/POS |
$859.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$907.25
|
| Rate for Payer: Three Rivers Provider Network All |
$716.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$840.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$238.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$888.15
|
| Rate for Payer: Zelis Auto |
$382.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$477.50
|
|
|
IMPLT MESH PLUG PREFIX LARGE
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$508.80 |
| Max. Negotiated Rate |
$1,208.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,017.60
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cigna Commercial |
$1,081.20
|
| Rate for Payer: First Health Commercial |
$1,144.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,144.80
|
| Rate for Payer: GEHA Commercial |
$890.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,144.80
|
| Rate for Payer: Multiplan All |
$1,157.52
|
| Rate for Payer: OMNI Networks Commercial |
$890.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,144.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,208.40
|
| Rate for Payer: Three Rivers Provider Network All |
$954.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,182.96
|
| Rate for Payer: Zelis Auto |
$508.80
|
|
|
IMPLT MESH PLUG PREFIX LARGE
|
Facility
|
OP
|
$1,272.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.00 |
| Max. Negotiated Rate |
$1,208.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$763.20
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cash Price |
$763.20
|
| Rate for Payer: Cigna Commercial |
$1,081.20
|
| Rate for Payer: First Health Commercial |
$1,144.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,144.80
|
| Rate for Payer: GEHA Commercial |
$1,017.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,144.80
|
| Rate for Payer: Humana ChoiceCare |
$330.72
|
| Rate for Payer: Multiplan All |
$1,157.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$763.20
|
| Rate for Payer: OMNI Networks Commercial |
$890.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,144.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,208.40
|
| Rate for Payer: Three Rivers Provider Network All |
$954.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,119.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$318.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,182.96
|
| Rate for Payer: Zelis Auto |
$508.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$636.00
|
|
|
IMPLT MESH PLUG PREFIX MEDIUM
|
Facility
|
IP
|
$1,284.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002382
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.60 |
| Max. Negotiated Rate |
$1,219.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,027.20
|
| Rate for Payer: Cash Price |
$770.40
|
| Rate for Payer: Cash Price |
$770.40
|
| Rate for Payer: Cigna Commercial |
$1,091.40
|
| Rate for Payer: First Health Commercial |
$1,155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,155.60
|
| Rate for Payer: GEHA Commercial |
$898.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,155.60
|
| Rate for Payer: Multiplan All |
$1,168.44
|
| Rate for Payer: OMNI Networks Commercial |
$898.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,155.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,219.80
|
| Rate for Payer: Three Rivers Provider Network All |
$963.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,194.12
|
| Rate for Payer: Zelis Auto |
$513.60
|
|
|
IMPLT MESH PLUG PREFIX MEDIUM
|
Facility
|
OP
|
$1,284.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002382
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$321.00 |
| Max. Negotiated Rate |
$1,219.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$770.40
|
| Rate for Payer: Cash Price |
$770.40
|
| Rate for Payer: Cash Price |
$770.40
|
| Rate for Payer: Cigna Commercial |
$1,091.40
|
| Rate for Payer: First Health Commercial |
$1,155.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,155.60
|
| Rate for Payer: GEHA Commercial |
$1,027.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,155.60
|
| Rate for Payer: Humana ChoiceCare |
$333.84
|
| Rate for Payer: Multiplan All |
$1,168.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$770.40
|
| Rate for Payer: OMNI Networks Commercial |
$898.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,155.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,219.80
|
| Rate for Payer: Three Rivers Provider Network All |
$963.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,129.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$321.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,194.12
|
| Rate for Payer: Zelis Auto |
$513.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$642.00
|
|
|
IMPLT MESH PLUG PREFIX SMALL
|
Facility
|
IP
|
$856.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$342.40 |
| Max. Negotiated Rate |
$813.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$684.80
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$727.60
|
| Rate for Payer: First Health Commercial |
$770.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$770.40
|
| Rate for Payer: GEHA Commercial |
$599.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$770.40
|
| Rate for Payer: Multiplan All |
$778.96
|
| Rate for Payer: OMNI Networks Commercial |
$599.20
|
| Rate for Payer: One Health Plan PPO/POS |
$770.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$813.20
|
| Rate for Payer: Three Rivers Provider Network All |
$642.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$796.08
|
| Rate for Payer: Zelis Auto |
$342.40
|
|
|
IMPLT MESH PLUG PREFIX SMALL
|
Facility
|
OP
|
$856.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.00 |
| Max. Negotiated Rate |
$813.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$727.60
|
| Rate for Payer: First Health Commercial |
$770.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$770.40
|
| Rate for Payer: GEHA Commercial |
$684.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$770.40
|
| Rate for Payer: Humana ChoiceCare |
$222.56
|
| Rate for Payer: Multiplan All |
$778.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$513.60
|
| Rate for Payer: OMNI Networks Commercial |
$599.20
|
| Rate for Payer: One Health Plan PPO/POS |
$770.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$813.20
|
| Rate for Payer: Three Rivers Provider Network All |
$642.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$753.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$214.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$796.08
|
| Rate for Payer: Zelis Auto |
$342.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$428.00
|
|
|
IMPLT MESH PLUG PREFIX X-LARGE
|
Facility
|
OP
|
$1,446.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$361.50 |
| Max. Negotiated Rate |
$1,373.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$867.60
|
| Rate for Payer: Cash Price |
$867.60
|
| Rate for Payer: Cash Price |
$867.60
|
| Rate for Payer: Cigna Commercial |
$1,229.10
|
| Rate for Payer: First Health Commercial |
$1,301.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,301.40
|
| Rate for Payer: GEHA Commercial |
$1,156.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,301.40
|
| Rate for Payer: Humana ChoiceCare |
$375.96
|
| Rate for Payer: Multiplan All |
$1,315.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$867.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,012.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,301.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,373.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,084.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,272.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$361.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,344.78
|
| Rate for Payer: Zelis Auto |
$578.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$723.00
|
|
|
IMPLT MESH PLUG PREFIX X-LARGE
|
Facility
|
IP
|
$1,446.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$578.40 |
| Max. Negotiated Rate |
$1,373.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,156.80
|
| Rate for Payer: Cash Price |
$867.60
|
| Rate for Payer: Cash Price |
$867.60
|
| Rate for Payer: Cigna Commercial |
$1,229.10
|
| Rate for Payer: First Health Commercial |
$1,301.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,301.40
|
| Rate for Payer: GEHA Commercial |
$1,012.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,301.40
|
| Rate for Payer: Multiplan All |
$1,315.86
|
| Rate for Payer: OMNI Networks Commercial |
$1,012.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,301.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,373.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,084.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,344.78
|
| Rate for Payer: Zelis Auto |
$578.40
|
|
|
IMPLT MESH PLUG PROLOOP LARGE
|
Facility
|
OP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$852.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Humana ChoiceCare |
$277.16
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$639.60
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$938.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$266.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$533.00
|
|
|
IMPLT MESH PLUG PROLOOP LARGE
|
Facility
|
IP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.40 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$852.80
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$746.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
|
|
IMPLT MESH PLUG PROLOOP MEDIUM
|
Facility
|
IP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.40 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$852.80
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$746.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
|
|
IMPLT MESH PLUG PROLOOP MEDIUM
|
Facility
|
OP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$852.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Humana ChoiceCare |
$277.16
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$639.60
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$938.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$266.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$533.00
|
|
|
IMPLT MESH PLUG PROLOOP SMALL
|
Facility
|
OP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$852.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Humana ChoiceCare |
$277.16
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$639.60
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$938.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$266.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$533.00
|
|
|
IMPLT MESH PLUG PROLOOP SMALL
|
Facility
|
IP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.40 |
| Max. Negotiated Rate |
$1,012.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$852.80
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cash Price |
$639.60
|
| Rate for Payer: Cigna Commercial |
$906.10
|
| Rate for Payer: First Health Commercial |
$959.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$959.40
|
| Rate for Payer: GEHA Commercial |
$746.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$959.40
|
| Rate for Payer: Multiplan All |
$970.06
|
| Rate for Payer: OMNI Networks Commercial |
$746.20
|
| Rate for Payer: One Health Plan PPO/POS |
$959.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,012.70
|
| Rate for Payer: Three Rivers Provider Network All |
$799.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$991.38
|
| Rate for Payer: Zelis Auto |
$426.40
|
|
