|
IMPLT MESH PLUG PROLOOP XLARGE
|
Facility
|
OP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002348
|
|
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 XLARGE
|
Facility
|
IP
|
$1,066.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002348
|
|
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 PREFIX LRG BARD
|
Facility
|
OP
|
$832.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$665.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Humana ChoiceCare |
$216.32
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$499.20
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$732.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$416.00
|
|
|
IMPLT MESH PREFIX LRG BARD
|
Facility
|
IP
|
$832.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$332.80 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$665.60
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$582.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
|
|
IMPLT MESH PREFIX X-LRG BARD
|
Facility
|
OP
|
$952.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$238.00 |
| Max. Negotiated Rate |
$904.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$571.20
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$809.20
|
| Rate for Payer: First Health Commercial |
$856.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$856.80
|
| Rate for Payer: GEHA Commercial |
$761.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$856.80
|
| Rate for Payer: Humana ChoiceCare |
$247.52
|
| Rate for Payer: Multiplan All |
$866.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$571.20
|
| Rate for Payer: OMNI Networks Commercial |
$666.40
|
| Rate for Payer: One Health Plan PPO/POS |
$856.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$904.40
|
| Rate for Payer: Three Rivers Provider Network All |
$714.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$837.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$238.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$885.36
|
| Rate for Payer: Zelis Auto |
$380.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$476.00
|
|
|
IMPLT MESH PREFIX X-LRG BARD
|
Facility
|
IP
|
$952.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002350
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$380.80 |
| Max. Negotiated Rate |
$904.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$761.60
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$809.20
|
| Rate for Payer: First Health Commercial |
$856.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$856.80
|
| Rate for Payer: GEHA Commercial |
$666.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$856.80
|
| Rate for Payer: Multiplan All |
$866.32
|
| Rate for Payer: OMNI Networks Commercial |
$666.40
|
| Rate for Payer: One Health Plan PPO/POS |
$856.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$904.40
|
| Rate for Payer: Three Rivers Provider Network All |
$714.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$885.36
|
| Rate for Payer: Zelis Auto |
$380.80
|
|
|
IMPLT MESH PROLENE 3D
|
Facility
|
IP
|
$1,351.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002808
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.40 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,080.80
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cigna Commercial |
$1,148.35
|
| Rate for Payer: First Health Commercial |
$1,215.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,215.90
|
| Rate for Payer: GEHA Commercial |
$945.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,215.90
|
| Rate for Payer: Multiplan All |
$1,229.41
|
| Rate for Payer: OMNI Networks Commercial |
$945.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,215.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,283.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,013.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,256.43
|
| Rate for Payer: Zelis Auto |
$540.40
|
|
|
IMPLT MESH PROLENE 3D
|
Facility
|
OP
|
$1,351.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$337.75 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cigna Commercial |
$1,148.35
|
| Rate for Payer: First Health Commercial |
$1,215.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,215.90
|
| Rate for Payer: GEHA Commercial |
$1,080.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,215.90
|
| Rate for Payer: Humana ChoiceCare |
$351.26
|
| Rate for Payer: Multiplan All |
$1,229.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$810.60
|
| Rate for Payer: OMNI Networks Commercial |
$945.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,215.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,283.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,013.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,188.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$337.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,256.43
|
| Rate for Payer: Zelis Auto |
$540.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$675.50
|
|
|
IMPLT MESH PROLENE 3D
|
Facility
|
IP
|
$1,351.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.40 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,080.80
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cigna Commercial |
$1,148.35
|
| Rate for Payer: First Health Commercial |
$1,215.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,215.90
|
| Rate for Payer: GEHA Commercial |
$945.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,215.90
|
| Rate for Payer: Multiplan All |
$1,229.41
|
| Rate for Payer: OMNI Networks Commercial |
$945.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,215.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,283.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,013.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,256.43
|
| Rate for Payer: Zelis Auto |
$540.40
|
|
|
IMPLT MESH PROLENE 3D
|
Facility
|
OP
|
$1,351.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002808
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$337.75 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cash Price |
$810.60
|
| Rate for Payer: Cigna Commercial |
$1,148.35
|
| Rate for Payer: First Health Commercial |
$1,215.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,215.90
|
| Rate for Payer: GEHA Commercial |
$1,080.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,215.90
|
| Rate for Payer: Humana ChoiceCare |
$351.26
|
| Rate for Payer: Multiplan All |
$1,229.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$810.60
|
| Rate for Payer: OMNI Networks Commercial |
$945.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,215.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,283.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,013.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,188.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$337.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,256.43
|
| Rate for Payer: Zelis Auto |
$540.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$675.50
|
|
|
IMPLT MESH PROLENE 6X6
|
Facility
|
IP
|
$2,456.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$982.40 |
| Max. Negotiated Rate |
$2,333.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,964.80
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$2,087.60
|
| Rate for Payer: First Health Commercial |
$2,210.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,210.40
|
| Rate for Payer: GEHA Commercial |
$1,719.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,210.40
|
| Rate for Payer: Multiplan All |
$2,234.96
|
| Rate for Payer: OMNI Networks Commercial |
$1,719.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,210.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,333.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,842.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,284.08
|
| Rate for Payer: Zelis Auto |
$982.40
|
|
|
IMPLT MESH PROLENE 6X6
|
Facility
|
OP
|
$2,456.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.00 |
| Max. Negotiated Rate |
$2,333.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,473.60
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$2,087.60
|
| Rate for Payer: First Health Commercial |
$2,210.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,210.40
|
| Rate for Payer: GEHA Commercial |
$1,964.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,210.40
|
| Rate for Payer: Humana ChoiceCare |
$638.56
|
| Rate for Payer: Multiplan All |
$2,234.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,473.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,719.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,210.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,333.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,842.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,161.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$614.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,284.08
|
| Rate for Payer: Zelis Auto |
$982.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,228.00
|
|
|
IMPLT MESH RECTANG 4X8
|
Facility
|
OP
|
$2,656.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$664.00 |
| Max. Negotiated Rate |
$2,523.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,593.60
|
| Rate for Payer: Cash Price |
$1,593.60
|
| Rate for Payer: Cash Price |
$1,593.60
|
| Rate for Payer: Cigna Commercial |
$2,257.60
|
| Rate for Payer: First Health Commercial |
$2,390.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,390.40
|
| Rate for Payer: GEHA Commercial |
$2,124.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,390.40
|
| Rate for Payer: Humana ChoiceCare |
$690.56
|
| Rate for Payer: Multiplan All |
$2,416.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,593.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,859.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,390.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,523.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,992.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,337.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$664.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,470.08
|
| Rate for Payer: Zelis Auto |
$1,062.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,328.00
|
|
|
IMPLT MESH RECTANG 4X8
|
Facility
|
IP
|
$2,656.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,062.40 |
| Max. Negotiated Rate |
$2,523.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,124.80
|
| Rate for Payer: Cash Price |
$1,593.60
|
| Rate for Payer: Cash Price |
$1,593.60
|
| Rate for Payer: Cigna Commercial |
$2,257.60
|
| Rate for Payer: First Health Commercial |
$2,390.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,390.40
|
| Rate for Payer: GEHA Commercial |
$1,859.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,390.40
|
| Rate for Payer: Multiplan All |
$2,416.96
|
| Rate for Payer: OMNI Networks Commercial |
$1,859.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,390.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,523.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,992.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,470.08
|
| Rate for Payer: Zelis Auto |
$1,062.40
|
|
|
IMPLT MESH SHEET SOFT 3X6
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.40 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$80.80
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$85.85
|
| Rate for Payer: First Health Commercial |
$90.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.90
|
| Rate for Payer: GEHA Commercial |
$70.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.90
|
| Rate for Payer: Multiplan All |
$91.91
|
| Rate for Payer: OMNI Networks Commercial |
$70.70
|
| Rate for Payer: One Health Plan PPO/POS |
$90.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.95
|
| Rate for Payer: Three Rivers Provider Network All |
$75.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.93
|
| Rate for Payer: Zelis Auto |
$40.40
|
|
|
IMPLT MESH SHEET SOFT 3X6
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$85.85
|
| Rate for Payer: First Health Commercial |
$90.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.90
|
| Rate for Payer: GEHA Commercial |
$80.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.90
|
| Rate for Payer: Humana ChoiceCare |
$26.26
|
| Rate for Payer: Multiplan All |
$91.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$60.60
|
| Rate for Payer: OMNI Networks Commercial |
$70.70
|
| Rate for Payer: One Health Plan PPO/POS |
$90.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.95
|
| Rate for Payer: Three Rivers Provider Network All |
$75.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$88.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.93
|
| Rate for Payer: Zelis Auto |
$40.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$50.50
|
|
|
IMPLT MESH SMALL PHASIX PLUG
|
Facility
|
OP
|
$1,968.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$492.00 |
| Max. Negotiated Rate |
$1,869.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,180.80
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$1,672.80
|
| Rate for Payer: First Health Commercial |
$1,771.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,771.20
|
| Rate for Payer: GEHA Commercial |
$1,574.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,771.20
|
| Rate for Payer: Humana ChoiceCare |
$511.68
|
| Rate for Payer: Multiplan All |
$1,790.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,180.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,377.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,771.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,869.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,476.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,731.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$492.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,830.24
|
| Rate for Payer: Zelis Auto |
$787.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$984.00
|
|
|
IMPLT MESH SMALL PHASIX PLUG
|
Facility
|
IP
|
$1,968.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$787.20 |
| Max. Negotiated Rate |
$1,869.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,574.40
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$1,672.80
|
| Rate for Payer: First Health Commercial |
$1,771.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,771.20
|
| Rate for Payer: GEHA Commercial |
$1,377.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,771.20
|
| Rate for Payer: Multiplan All |
$1,790.88
|
| Rate for Payer: OMNI Networks Commercial |
$1,377.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,771.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,869.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,476.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,830.24
|
| Rate for Payer: Zelis Auto |
$787.20
|
|
|
IMPLT MESH SORBAFIX 15 ABSORBABLE
|
Facility
|
IP
|
$1,512.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$604.80 |
| Max. Negotiated Rate |
$1,436.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,209.60
|
| Rate for Payer: Cash Price |
$907.20
|
| Rate for Payer: Cash Price |
$907.20
|
| Rate for Payer: Cigna Commercial |
$1,285.20
|
| Rate for Payer: First Health Commercial |
$1,360.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,360.80
|
| Rate for Payer: GEHA Commercial |
$1,058.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,360.80
|
| Rate for Payer: Multiplan All |
$1,375.92
|
| Rate for Payer: OMNI Networks Commercial |
$1,058.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,360.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,436.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,134.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,406.16
|
| Rate for Payer: Zelis Auto |
$604.80
|
|
|
IMPLT MESH SORBAFIX 15 ABSORBABLE
|
Facility
|
OP
|
$1,512.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$378.00 |
| Max. Negotiated Rate |
$1,436.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$907.20
|
| Rate for Payer: Cash Price |
$907.20
|
| Rate for Payer: Cash Price |
$907.20
|
| Rate for Payer: Cigna Commercial |
$1,285.20
|
| Rate for Payer: First Health Commercial |
$1,360.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,360.80
|
| Rate for Payer: GEHA Commercial |
$1,209.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,360.80
|
| Rate for Payer: Humana ChoiceCare |
$393.12
|
| Rate for Payer: Multiplan All |
$1,375.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$907.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,058.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,360.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,436.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,134.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,330.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$378.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,406.16
|
| Rate for Payer: Zelis Auto |
$604.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$756.00
|
|
|
IMPLT MESH SQUARE 6X6
|
Facility
|
OP
|
$2,749.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$687.25 |
| Max. Negotiated Rate |
$2,611.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,649.40
|
| Rate for Payer: Cash Price |
$1,649.40
|
| Rate for Payer: Cash Price |
$1,649.40
|
| Rate for Payer: Cigna Commercial |
$2,336.65
|
| Rate for Payer: First Health Commercial |
$2,474.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,474.10
|
| Rate for Payer: GEHA Commercial |
$2,199.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,474.10
|
| Rate for Payer: Humana ChoiceCare |
$714.74
|
| Rate for Payer: Multiplan All |
$2,501.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,649.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,924.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,474.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,611.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,061.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,419.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$687.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,556.57
|
| Rate for Payer: Zelis Auto |
$1,099.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,374.50
|
|
|
IMPLT MESH SQUARE 6X6
|
Facility
|
IP
|
$2,749.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,099.60 |
| Max. Negotiated Rate |
$2,611.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,199.20
|
| Rate for Payer: Cash Price |
$1,649.40
|
| Rate for Payer: Cash Price |
$1,649.40
|
| Rate for Payer: Cigna Commercial |
$2,336.65
|
| Rate for Payer: First Health Commercial |
$2,474.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,474.10
|
| Rate for Payer: GEHA Commercial |
$1,924.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,474.10
|
| Rate for Payer: Multiplan All |
$2,501.59
|
| Rate for Payer: OMNI Networks Commercial |
$1,924.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,474.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,611.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,061.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,556.57
|
| Rate for Payer: Zelis Auto |
$1,099.60
|
|
|
IMPLT MESH VENTRALEX LARGE 0010303
|
Facility
|
IP
|
$3,103.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,241.20 |
| Max. Negotiated Rate |
$2,947.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,482.40
|
| Rate for Payer: Cash Price |
$1,861.80
|
| Rate for Payer: Cash Price |
$1,861.80
|
| Rate for Payer: Cigna Commercial |
$2,637.55
|
| Rate for Payer: First Health Commercial |
$2,792.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,792.70
|
| Rate for Payer: GEHA Commercial |
$2,172.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,792.70
|
| Rate for Payer: Multiplan All |
$2,823.73
|
| Rate for Payer: OMNI Networks Commercial |
$2,172.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,792.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,947.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,327.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,885.79
|
| Rate for Payer: Zelis Auto |
$1,241.20
|
|
|
IMPLT MESH VENTRALEX LARGE 0010303
|
Facility
|
OP
|
$3,103.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002352
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$775.75 |
| Max. Negotiated Rate |
$2,947.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,861.80
|
| Rate for Payer: Cash Price |
$1,861.80
|
| Rate for Payer: Cash Price |
$1,861.80
|
| Rate for Payer: Cigna Commercial |
$2,637.55
|
| Rate for Payer: First Health Commercial |
$2,792.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,792.70
|
| Rate for Payer: GEHA Commercial |
$2,482.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,792.70
|
| Rate for Payer: Humana ChoiceCare |
$806.78
|
| Rate for Payer: Multiplan All |
$2,823.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,861.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,172.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,792.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,947.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,327.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,730.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$775.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,885.79
|
| Rate for Payer: Zelis Auto |
$1,241.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,551.50
|
|
|
IMPLT MESH VENTRALEX MEDIUM 0010302
|
Facility
|
OP
|
$2,866.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002353
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$716.50 |
| Max. Negotiated Rate |
$2,722.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,719.60
|
| Rate for Payer: Cash Price |
$1,719.60
|
| Rate for Payer: Cash Price |
$1,719.60
|
| Rate for Payer: Cigna Commercial |
$2,436.10
|
| Rate for Payer: First Health Commercial |
$2,579.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,579.40
|
| Rate for Payer: GEHA Commercial |
$2,292.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,579.40
|
| Rate for Payer: Humana ChoiceCare |
$745.16
|
| Rate for Payer: Multiplan All |
$2,608.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,719.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,006.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,579.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,722.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,149.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,522.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$716.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,665.38
|
| Rate for Payer: Zelis Auto |
$1,146.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,433.00
|
|
