|
IMPLT POL ULTRA 7FX24CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006728
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 7FX26CM
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.75 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$661.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Humana ChoiceCare |
$215.02
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$496.20
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$727.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$413.50
|
|
|
IMPLT POL ULTRA 7FX26CM
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.80 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$661.60
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$578.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
|
|
IMPLT POL ULTRA 7FX28CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 7FX28CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006729
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 7FX30CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 7FX30CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 8FX20CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 8FX20CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 8FX22CM
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.75 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$661.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Humana ChoiceCare |
$215.02
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$496.20
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$727.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$413.50
|
|
|
IMPLT POL ULTRA 8FX22CM
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.80 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$661.60
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$578.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
|
|
IMPLT POL ULTRA 8FX24CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 8FX24CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 8FX26CM
|
Facility
|
OP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.75 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$661.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Humana ChoiceCare |
$215.02
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$496.20
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$727.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$206.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$413.50
|
|
|
IMPLT POL ULTRA 8FX26CM
|
Facility
|
IP
|
$827.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.80 |
| Max. Negotiated Rate |
$785.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$661.60
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$702.95
|
| Rate for Payer: First Health Commercial |
$744.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$744.30
|
| Rate for Payer: GEHA Commercial |
$578.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$744.30
|
| Rate for Payer: Multiplan All |
$752.57
|
| Rate for Payer: OMNI Networks Commercial |
$578.90
|
| Rate for Payer: One Health Plan PPO/POS |
$744.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$785.65
|
| Rate for Payer: Three Rivers Provider Network All |
$620.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$769.11
|
| Rate for Payer: Zelis Auto |
$330.80
|
|
|
IMPLT POL ULTRA 8FX28CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 8FX28CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POL ULTRA 8FX30CM
|
Facility
|
IP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$625.60
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$547.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
|
|
IMPLT POL ULTRA 8FX30CM
|
Facility
|
OP
|
$782.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$742.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$664.70
|
| Rate for Payer: First Health Commercial |
$703.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$703.80
|
| Rate for Payer: GEHA Commercial |
$625.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$703.80
|
| Rate for Payer: Humana ChoiceCare |
$203.32
|
| Rate for Payer: Multiplan All |
$711.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$469.20
|
| Rate for Payer: OMNI Networks Commercial |
$547.40
|
| Rate for Payer: One Health Plan PPO/POS |
$703.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$742.90
|
| Rate for Payer: Three Rivers Provider Network All |
$586.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$688.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$195.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$727.26
|
| Rate for Payer: Zelis Auto |
$312.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$391.00
|
|
|
IMPLT POLYETHYLENE INSERT 36MM
|
Facility
|
OP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$944.00 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$3,020.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Humana ChoiceCare |
$981.76
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,265.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,322.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$944.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,888.00
|
|
|
IMPLT POLYETHYLENE INSERT 36MM
|
Facility
|
IP
|
$3,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.40 |
| Max. Negotiated Rate |
$3,587.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,020.80
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cash Price |
$2,265.60
|
| Rate for Payer: Cigna Commercial |
$3,209.60
|
| Rate for Payer: First Health Commercial |
$3,398.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,398.40
|
| Rate for Payer: GEHA Commercial |
$2,643.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,398.40
|
| Rate for Payer: Multiplan All |
$3,436.16
|
| Rate for Payer: OMNI Networks Commercial |
$2,643.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,398.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,587.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,832.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,511.68
|
| Rate for Payer: Zelis Auto |
$1,510.40
|
|
|
IMPLT POROUS COATED PROXIMAL SLEEVE
|
Facility
|
IP
|
$6,292.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,516.80 |
| Max. Negotiated Rate |
$5,977.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,033.60
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$5,348.20
|
| Rate for Payer: First Health Commercial |
$5,662.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,662.80
|
| Rate for Payer: GEHA Commercial |
$4,404.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,662.80
|
| Rate for Payer: Multiplan All |
$5,725.72
|
| Rate for Payer: OMNI Networks Commercial |
$4,404.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,662.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,977.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,719.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,851.56
|
| Rate for Payer: Zelis Auto |
$2,516.80
|
|
|
IMPLT POROUS COATED PROXIMAL SLEEVE
|
Facility
|
OP
|
$6,292.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,573.00 |
| Max. Negotiated Rate |
$5,977.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$5,348.20
|
| Rate for Payer: First Health Commercial |
$5,662.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,662.80
|
| Rate for Payer: GEHA Commercial |
$5,033.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,662.80
|
| Rate for Payer: Humana ChoiceCare |
$1,635.92
|
| Rate for Payer: Multiplan All |
$5,725.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,775.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,404.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,662.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,977.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,719.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,536.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,573.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,851.56
|
| Rate for Payer: Zelis Auto |
$2,516.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,146.00
|
|
|
IMPLT PORT MRI LOW PROF SINGLE LUMEN
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$456.40 |
| Max. Negotiated Rate |
$1,083.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$912.80
|
| Rate for Payer: Cash Price |
$684.60
|
| Rate for Payer: Cash Price |
$684.60
|
| Rate for Payer: Cigna Commercial |
$969.85
|
| Rate for Payer: First Health Commercial |
$1,026.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,026.90
|
| Rate for Payer: GEHA Commercial |
$798.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,026.90
|
| Rate for Payer: Multiplan All |
$1,038.31
|
| Rate for Payer: OMNI Networks Commercial |
$798.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,026.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,083.95
|
| Rate for Payer: Three Rivers Provider Network All |
$855.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,061.13
|
| Rate for Payer: Zelis Auto |
$456.40
|
|
|
IMPLT PORT MRI LOW PROF SINGLE LUMEN
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.25 |
| Max. Negotiated Rate |
$1,083.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$684.60
|
| Rate for Payer: Cash Price |
$684.60
|
| Rate for Payer: Cash Price |
$684.60
|
| Rate for Payer: Cigna Commercial |
$969.85
|
| Rate for Payer: First Health Commercial |
$1,026.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,026.90
|
| Rate for Payer: GEHA Commercial |
$912.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,026.90
|
| Rate for Payer: Humana ChoiceCare |
$296.66
|
| Rate for Payer: Multiplan All |
$1,038.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$684.60
|
| Rate for Payer: OMNI Networks Commercial |
$798.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,026.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,083.95
|
| Rate for Payer: Three Rivers Provider Network All |
$855.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,004.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$285.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,061.13
|
| Rate for Payer: Zelis Auto |
$456.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$570.50
|
|
