|
IMPLT NEUROSTIMULATOR INTELLIS
|
Facility
|
IP
|
$48,750.00
|
|
|
Service Code
|
CPT C1820
|
| Hospital Charge Code |
7003154
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19,500.00 |
| Max. Negotiated Rate |
$46,312.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39,000.00
|
| Rate for Payer: Cash Price |
$29,250.00
|
| Rate for Payer: Cash Price |
$29,250.00
|
| Rate for Payer: Cigna Commercial |
$41,437.50
|
| Rate for Payer: First Health Commercial |
$43,875.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43,875.00
|
| Rate for Payer: GEHA Commercial |
$34,125.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43,875.00
|
| Rate for Payer: Multiplan All |
$44,362.50
|
| Rate for Payer: OMNI Networks Commercial |
$34,125.00
|
| Rate for Payer: One Health Plan PPO/POS |
$43,875.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46,312.50
|
| Rate for Payer: Three Rivers Provider Network All |
$36,562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45,337.50
|
| Rate for Payer: Zelis Auto |
$19,500.00
|
|
|
IMPLT NEUROSTIMULATOR INTELLIS
|
Facility
|
OP
|
$48,750.00
|
|
|
Service Code
|
CPT C1820
|
| Hospital Charge Code |
7003154
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,187.50 |
| Max. Negotiated Rate |
$46,312.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$29,250.00
|
| Rate for Payer: Cash Price |
$29,250.00
|
| Rate for Payer: Cash Price |
$29,250.00
|
| Rate for Payer: Cigna Commercial |
$41,437.50
|
| Rate for Payer: First Health Commercial |
$43,875.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$43,875.00
|
| Rate for Payer: GEHA Commercial |
$39,000.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$43,875.00
|
| Rate for Payer: Humana ChoiceCare |
$12,675.00
|
| Rate for Payer: Multiplan All |
$44,362.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$29,250.00
|
| Rate for Payer: OMNI Networks Commercial |
$34,125.00
|
| Rate for Payer: One Health Plan PPO/POS |
$43,875.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$46,312.50
|
| Rate for Payer: Three Rivers Provider Network All |
$36,562.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$42,900.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$12,187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$45,337.50
|
| Rate for Payer: Zelis Auto |
$19,500.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$24,375.00
|
|
|
IMPLT NEUROSTIMULATOR INTERSTIM I I
|
Facility
|
IP
|
$34,941.00
|
|
|
Service Code
|
CPT C1820
|
| Hospital Charge Code |
7002394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,976.40 |
| Max. Negotiated Rate |
$33,193.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$27,952.80
|
| Rate for Payer: Cash Price |
$20,964.60
|
| Rate for Payer: Cash Price |
$20,964.60
|
| Rate for Payer: Cigna Commercial |
$29,699.85
|
| Rate for Payer: First Health Commercial |
$31,446.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31,446.90
|
| Rate for Payer: GEHA Commercial |
$24,458.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31,446.90
|
| Rate for Payer: Multiplan All |
$31,796.31
|
| Rate for Payer: OMNI Networks Commercial |
$24,458.70
|
| Rate for Payer: One Health Plan PPO/POS |
$31,446.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33,193.95
|
| Rate for Payer: Three Rivers Provider Network All |
$26,205.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32,495.13
|
| Rate for Payer: Zelis Auto |
$13,976.40
|
|
|
IMPLT NEUROSTIMULATOR INTERSTIM I I
|
Facility
|
OP
|
$34,941.00
|
|
|
Service Code
|
CPT C1820
|
| Hospital Charge Code |
7002394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,735.25 |
| Max. Negotiated Rate |
$33,193.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20,964.60
|
| Rate for Payer: Cash Price |
$20,964.60
|
| Rate for Payer: Cash Price |
$20,964.60
|
| Rate for Payer: Cigna Commercial |
$29,699.85
|
| Rate for Payer: First Health Commercial |
$31,446.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$31,446.90
|
| Rate for Payer: GEHA Commercial |
$27,952.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$31,446.90
|
| Rate for Payer: Humana ChoiceCare |
$9,084.66
|
| Rate for Payer: Multiplan All |
$31,796.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$20,964.60
|
| Rate for Payer: OMNI Networks Commercial |
$24,458.70
|
| Rate for Payer: One Health Plan PPO/POS |
$31,446.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$33,193.95
|
| Rate for Payer: Three Rivers Provider Network All |
$26,205.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$30,748.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$8,735.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$32,495.13
|
| Rate for Payer: Zelis Auto |
$13,976.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$17,470.50
|
|
|
IMPLT NUT CONDYLE SCREW 05MM
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$345.60 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$691.20
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cigna Commercial |
$734.40
|
| Rate for Payer: First Health Commercial |
$777.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$777.60
|
| Rate for Payer: GEHA Commercial |
$604.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$777.60
|
| Rate for Payer: Multiplan All |
$786.24
|
| Rate for Payer: OMNI Networks Commercial |
$604.80
|
| Rate for Payer: One Health Plan PPO/POS |
$777.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$820.80
|
| Rate for Payer: Three Rivers Provider Network All |
$648.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$803.52
|
| Rate for Payer: Zelis Auto |
$345.60
|
|
|
IMPLT NUT CONDYLE SCREW 05MM
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$518.40
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cigna Commercial |
$734.40
|
| Rate for Payer: First Health Commercial |
$777.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$777.60
|
| Rate for Payer: GEHA Commercial |
$691.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$777.60
|
| Rate for Payer: Humana ChoiceCare |
$224.64
|
| Rate for Payer: Multiplan All |
$786.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$518.40
|
| Rate for Payer: OMNI Networks Commercial |
$604.80
|
| Rate for Payer: One Health Plan PPO/POS |
$777.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$820.80
|
| Rate for Payer: Three Rivers Provider Network All |
$648.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$760.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$216.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$803.52
|
| Rate for Payer: Zelis Auto |
$345.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$432.00
|
|
|
IMPLT OASIS MATRIX 7X10CM
|
Facility
|
OP
|
$3,426.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$3,254.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,055.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.06
|
| Rate for Payer: Cash Price |
$2,055.60
|
| Rate for Payer: Cash Price |
$2,055.60
|
| Rate for Payer: Cigna Commercial |
$2,912.10
|
| Rate for Payer: First Health Commercial |
$3,083.40
|
| Rate for Payer: First Health Workers Compensation |
$1,322.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,083.40
|
| Rate for Payer: GEHA Commercial |
$13.07
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,083.40
|
| Rate for Payer: Humana ChoiceCare |
$890.76
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$13.33
|
| Rate for Payer: Multiplan All |
$3,117.66
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,055.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,398.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,083.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$15.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$13.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,254.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,569.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,014.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,186.18
|
| Rate for Payer: Zelis Auto |
$1,370.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,713.00
|
| Rate for Payer: Zelis Worker's Compensation |
$935.30
|
|
|
IMPLT OASIS MATRIX 7X10CM
|
Facility
|
IP
|
$3,426.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$935.30 |
| Max. Negotiated Rate |
$3,254.70 |
| Rate for Payer: Cash Price |
$2,055.60
|
| Rate for Payer: Cigna Commercial |
$2,912.10
|
| Rate for Payer: First Health Commercial |
$3,083.40
|
| Rate for Payer: First Health Workers Compensation |
$1,322.78
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,083.40
|
| Rate for Payer: GEHA Commercial |
$2,398.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,083.40
|
| Rate for Payer: Multiplan All |
$3,117.66
|
| Rate for Payer: OMNI Networks Commercial |
$2,398.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,083.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,254.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,569.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,186.18
|
| Rate for Payer: Zelis Auto |
$1,370.40
|
| Rate for Payer: Zelis Worker's Compensation |
$935.30
|
|
|
IMPLT OFFSET FEMORAL CEMENTED 12/14
|
Facility
|
IP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.00 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,812.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,335.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
|
|
IMPLT OFFSET FEMORAL CEMENTED 12/14
|
Facility
|
OP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,191.25 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Humana ChoiceCare |
$1,238.90
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,859.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,193.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,191.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,382.50
|
|
|
IMPLT OFFSET TIBIAL TRAY STEM
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$293.75 |
| Max. Negotiated Rate |
$1,116.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$705.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cigna Commercial |
$998.75
|
| Rate for Payer: First Health Commercial |
$1,057.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,057.50
|
| Rate for Payer: GEHA Commercial |
$940.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,057.50
|
| Rate for Payer: Humana ChoiceCare |
$305.50
|
| Rate for Payer: Multiplan All |
$1,069.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$705.00
|
| Rate for Payer: OMNI Networks Commercial |
$822.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,057.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,116.25
|
| Rate for Payer: Three Rivers Provider Network All |
$881.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,034.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$293.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,092.75
|
| Rate for Payer: Zelis Auto |
$470.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$587.50
|
|
|
IMPLT OFFSET TIBIAL TRAY STEM
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.00 |
| Max. Negotiated Rate |
$1,116.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$940.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cash Price |
$705.00
|
| Rate for Payer: Cigna Commercial |
$998.75
|
| Rate for Payer: First Health Commercial |
$1,057.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,057.50
|
| Rate for Payer: GEHA Commercial |
$822.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,057.50
|
| Rate for Payer: Multiplan All |
$1,069.25
|
| Rate for Payer: OMNI Networks Commercial |
$822.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,057.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,116.25
|
| Rate for Payer: Three Rivers Provider Network All |
$881.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,092.75
|
| Rate for Payer: Zelis Auto |
$470.00
|
|
|
IMPLT OSTEOSET FC BEADS
|
Facility
|
IP
|
$3,706.21
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,482.48 |
| Max. Negotiated Rate |
$3,520.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,964.97
|
| Rate for Payer: Cash Price |
$2,223.73
|
| Rate for Payer: Cash Price |
$2,223.73
|
| Rate for Payer: Cigna Commercial |
$3,150.28
|
| Rate for Payer: First Health Commercial |
$3,335.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,335.59
|
| Rate for Payer: GEHA Commercial |
$2,594.35
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,335.59
|
| Rate for Payer: Multiplan All |
$3,372.65
|
| Rate for Payer: OMNI Networks Commercial |
$2,594.35
|
| Rate for Payer: One Health Plan PPO/POS |
$3,335.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,520.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,779.66
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,446.78
|
| Rate for Payer: Zelis Auto |
$1,482.48
|
|
|
IMPLT OSTEOSET FC BEADS
|
Facility
|
OP
|
$3,706.21
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.55 |
| Max. Negotiated Rate |
$3,520.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,223.73
|
| Rate for Payer: Cash Price |
$2,223.73
|
| Rate for Payer: Cash Price |
$2,223.73
|
| Rate for Payer: Cigna Commercial |
$3,150.28
|
| Rate for Payer: First Health Commercial |
$3,335.59
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,335.59
|
| Rate for Payer: GEHA Commercial |
$2,964.97
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,335.59
|
| Rate for Payer: Humana ChoiceCare |
$963.61
|
| Rate for Payer: Multiplan All |
$3,372.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,223.73
|
| Rate for Payer: OMNI Networks Commercial |
$2,594.35
|
| Rate for Payer: One Health Plan PPO/POS |
$3,335.59
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,520.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,779.66
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,261.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$926.55
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,446.78
|
| Rate for Payer: Zelis Auto |
$1,482.48
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,853.11
|
|
|
IMPLT OSTEOSET FC BEADS 5CC
|
Facility
|
IP
|
$2,938.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,175.20 |
| Max. Negotiated Rate |
$2,791.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,350.40
|
| Rate for Payer: Cash Price |
$1,762.80
|
| Rate for Payer: Cash Price |
$1,762.80
|
| Rate for Payer: Cigna Commercial |
$2,497.30
|
| Rate for Payer: First Health Commercial |
$2,644.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,644.20
|
| Rate for Payer: GEHA Commercial |
$2,056.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,644.20
|
| Rate for Payer: Multiplan All |
$2,673.58
|
| Rate for Payer: OMNI Networks Commercial |
$2,056.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,644.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,791.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,203.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,732.34
|
| Rate for Payer: Zelis Auto |
$1,175.20
|
|
|
IMPLT OSTEOSET FC BEADS 5CC
|
Facility
|
OP
|
$2,938.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$734.50 |
| Max. Negotiated Rate |
$2,791.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,762.80
|
| Rate for Payer: Cash Price |
$1,762.80
|
| Rate for Payer: Cash Price |
$1,762.80
|
| Rate for Payer: Cigna Commercial |
$2,497.30
|
| Rate for Payer: First Health Commercial |
$2,644.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,644.20
|
| Rate for Payer: GEHA Commercial |
$2,350.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,644.20
|
| Rate for Payer: Humana ChoiceCare |
$763.88
|
| Rate for Payer: Multiplan All |
$2,673.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,762.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,056.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,644.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,791.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,203.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,585.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$734.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,732.34
|
| Rate for Payer: Zelis Auto |
$1,175.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,469.00
|
|
|
IMPLT PACK PREP SLIC SCREW
|
Facility
|
IP
|
$3,992.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,596.80 |
| Max. Negotiated Rate |
$3,792.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,193.60
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cigna Commercial |
$3,393.20
|
| Rate for Payer: First Health Commercial |
$3,592.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,592.80
|
| Rate for Payer: GEHA Commercial |
$2,794.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,592.80
|
| Rate for Payer: Multiplan All |
$3,632.72
|
| Rate for Payer: OMNI Networks Commercial |
$2,794.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,592.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,792.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,994.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,712.56
|
| Rate for Payer: Zelis Auto |
$1,596.80
|
|
|
IMPLT PACK PREP SLIC SCREW
|
Facility
|
OP
|
$3,992.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$998.00 |
| Max. Negotiated Rate |
$3,792.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cigna Commercial |
$3,393.20
|
| Rate for Payer: First Health Commercial |
$3,592.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,592.80
|
| Rate for Payer: GEHA Commercial |
$3,193.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,592.80
|
| Rate for Payer: Humana ChoiceCare |
$1,037.92
|
| Rate for Payer: Multiplan All |
$3,632.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,395.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,794.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,592.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,792.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,994.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,512.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$998.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,712.56
|
| Rate for Payer: Zelis Auto |
$1,596.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,996.00
|
|
|
IMPLT PACK SCREW SLIC 28MM
|
Facility
|
IP
|
$3,992.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,596.80 |
| Max. Negotiated Rate |
$3,792.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,193.60
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cigna Commercial |
$3,393.20
|
| Rate for Payer: First Health Commercial |
$3,592.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,592.80
|
| Rate for Payer: GEHA Commercial |
$2,794.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,592.80
|
| Rate for Payer: Multiplan All |
$3,632.72
|
| Rate for Payer: OMNI Networks Commercial |
$2,794.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,592.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,792.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,994.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,712.56
|
| Rate for Payer: Zelis Auto |
$1,596.80
|
|
|
IMPLT PACK SCREW SLIC 28MM
|
Facility
|
OP
|
$3,992.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$998.00 |
| Max. Negotiated Rate |
$3,792.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cash Price |
$2,395.20
|
| Rate for Payer: Cigna Commercial |
$3,393.20
|
| Rate for Payer: First Health Commercial |
$3,592.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,592.80
|
| Rate for Payer: GEHA Commercial |
$3,193.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,592.80
|
| Rate for Payer: Humana ChoiceCare |
$1,037.92
|
| Rate for Payer: Multiplan All |
$3,632.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,395.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,794.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,592.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,792.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,994.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,512.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$998.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,712.56
|
| Rate for Payer: Zelis Auto |
$1,596.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,996.00
|
|
|
IMPLT PACK SLIC SCREW 25MM
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.25 |
| Max. Negotiated Rate |
$506.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$319.80
|
| Rate for Payer: Cash Price |
$319.80
|
| Rate for Payer: Cash Price |
$319.80
|
| Rate for Payer: Cigna Commercial |
$453.05
|
| Rate for Payer: First Health Commercial |
$479.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$479.70
|
| Rate for Payer: GEHA Commercial |
$426.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$479.70
|
| Rate for Payer: Humana ChoiceCare |
$138.58
|
| Rate for Payer: Multiplan All |
$485.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$319.80
|
| Rate for Payer: OMNI Networks Commercial |
$373.10
|
| Rate for Payer: One Health Plan PPO/POS |
$479.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$506.35
|
| Rate for Payer: Three Rivers Provider Network All |
$399.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$469.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$133.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$495.69
|
| Rate for Payer: Zelis Auto |
$213.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$266.50
|
|
|
IMPLT PACK SLIC SCREW 25MM
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$213.20 |
| Max. Negotiated Rate |
$506.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$426.40
|
| Rate for Payer: Cash Price |
$319.80
|
| Rate for Payer: Cash Price |
$319.80
|
| Rate for Payer: Cigna Commercial |
$453.05
|
| Rate for Payer: First Health Commercial |
$479.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$479.70
|
| Rate for Payer: GEHA Commercial |
$373.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$479.70
|
| Rate for Payer: Multiplan All |
$485.03
|
| Rate for Payer: OMNI Networks Commercial |
$373.10
|
| Rate for Payer: One Health Plan PPO/POS |
$479.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$506.35
|
| Rate for Payer: Three Rivers Provider Network All |
$399.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$495.69
|
| Rate for Payer: Zelis Auto |
$213.20
|
|
|
IMPLT PALACOS R+G 1X40 SING W/GENTAMICIN
|
Facility
|
OP
|
$1,457.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$364.25 |
| Max. Negotiated Rate |
$1,384.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$874.20
|
| Rate for Payer: Cash Price |
$874.20
|
| Rate for Payer: Cash Price |
$874.20
|
| Rate for Payer: Cigna Commercial |
$1,238.45
|
| Rate for Payer: First Health Commercial |
$1,311.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,311.30
|
| Rate for Payer: GEHA Commercial |
$1,165.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,311.30
|
| Rate for Payer: Humana ChoiceCare |
$378.82
|
| Rate for Payer: Multiplan All |
$1,325.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$874.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,019.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,311.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,384.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,092.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,282.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$364.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,355.01
|
| Rate for Payer: Zelis Auto |
$582.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$728.50
|
|
|
IMPLT PALACOS R+G 1X40 SING W/GENTAMICIN
|
Facility
|
IP
|
$1,457.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.80 |
| Max. Negotiated Rate |
$1,384.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,165.60
|
| Rate for Payer: Cash Price |
$874.20
|
| Rate for Payer: Cash Price |
$874.20
|
| Rate for Payer: Cigna Commercial |
$1,238.45
|
| Rate for Payer: First Health Commercial |
$1,311.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,311.30
|
| Rate for Payer: GEHA Commercial |
$1,019.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,311.30
|
| Rate for Payer: Multiplan All |
$1,325.87
|
| Rate for Payer: OMNI Networks Commercial |
$1,019.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,311.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,384.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,092.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,355.01
|
| Rate for Payer: Zelis Auto |
$582.80
|
|
|
IMPLT PARTIALLY THREADED 205.044
|
Facility
|
OP
|
$1,164.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$291.00 |
| Max. Negotiated Rate |
$1,105.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$698.40
|
| Rate for Payer: Cash Price |
$698.40
|
| Rate for Payer: Cash Price |
$698.40
|
| Rate for Payer: Cigna Commercial |
$989.40
|
| Rate for Payer: First Health Commercial |
$1,047.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,047.60
|
| Rate for Payer: GEHA Commercial |
$931.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,047.60
|
| Rate for Payer: Humana ChoiceCare |
$302.64
|
| Rate for Payer: Multiplan All |
$1,059.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$698.40
|
| Rate for Payer: OMNI Networks Commercial |
$814.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,047.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,105.80
|
| Rate for Payer: Three Rivers Provider Network All |
$873.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,024.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$291.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,082.52
|
| Rate for Payer: Zelis Auto |
$465.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$582.00
|
|
