|
IMPLT PROSTHESIS PENILE SPECTRA 12X16CM
|
Facility
|
OP
|
$23,014.00
|
|
|
Service Code
|
CPT C2622
|
| Hospital Charge Code |
7006128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,753.50 |
| Max. Negotiated Rate |
$21,863.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13,808.40
|
| Rate for Payer: Cash Price |
$13,808.40
|
| Rate for Payer: Cash Price |
$13,808.40
|
| Rate for Payer: Cigna Commercial |
$19,561.90
|
| Rate for Payer: First Health Commercial |
$20,712.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20,712.60
|
| Rate for Payer: GEHA Commercial |
$18,411.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20,712.60
|
| Rate for Payer: Humana ChoiceCare |
$5,983.64
|
| Rate for Payer: Multiplan All |
$20,942.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$13,808.40
|
| Rate for Payer: OMNI Networks Commercial |
$16,109.80
|
| Rate for Payer: One Health Plan PPO/POS |
$20,712.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21,863.30
|
| Rate for Payer: Three Rivers Provider Network All |
$17,260.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$20,252.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,753.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21,403.02
|
| Rate for Payer: Zelis Auto |
$9,205.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$11,507.00
|
|
|
IMPLT PROSTHESIS PENILE SPECTRA 12X16CM
|
Facility
|
IP
|
$23,014.00
|
|
|
Service Code
|
CPT C2622
|
| Hospital Charge Code |
7006128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,205.60 |
| Max. Negotiated Rate |
$21,863.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$18,411.20
|
| Rate for Payer: Cash Price |
$13,808.40
|
| Rate for Payer: Cash Price |
$13,808.40
|
| Rate for Payer: Cigna Commercial |
$19,561.90
|
| Rate for Payer: First Health Commercial |
$20,712.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$20,712.60
|
| Rate for Payer: GEHA Commercial |
$16,109.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$20,712.60
|
| Rate for Payer: Multiplan All |
$20,942.74
|
| Rate for Payer: OMNI Networks Commercial |
$16,109.80
|
| Rate for Payer: One Health Plan PPO/POS |
$20,712.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$21,863.30
|
| Rate for Payer: Three Rivers Provider Network All |
$17,260.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$21,403.02
|
| Rate for Payer: Zelis Auto |
$9,205.60
|
|
|
IMPLT PROSTHESIS PHALANGEAL ANATOEMIC 20
|
Facility
|
OP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$946.25 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$3,028.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Humana ChoiceCare |
$984.10
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,271.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,330.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$946.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,892.50
|
|
|
IMPLT PROSTHESIS PHALANGEAL ANATOEMIC 20
|
Facility
|
IP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002126
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,514.00 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,028.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$2,649.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
|
|
IMPLT PROSTHESIS RICHARDS
|
Facility
|
IP
|
$520.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$494.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$416.00
|
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cigna Commercial |
$442.00
|
| Rate for Payer: First Health Commercial |
$468.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$468.00
|
| Rate for Payer: GEHA Commercial |
$364.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$468.00
|
| Rate for Payer: Multiplan All |
$473.20
|
| Rate for Payer: OMNI Networks Commercial |
$364.00
|
| Rate for Payer: One Health Plan PPO/POS |
$468.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$494.00
|
| Rate for Payer: Three Rivers Provider Network All |
$390.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$483.60
|
| Rate for Payer: Zelis Auto |
$208.00
|
|
|
IMPLT PROSTHESIS RICHARDS
|
Facility
|
OP
|
$520.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$494.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$312.00
|
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cash Price |
$312.00
|
| Rate for Payer: Cigna Commercial |
$442.00
|
| Rate for Payer: First Health Commercial |
$468.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$468.00
|
| Rate for Payer: GEHA Commercial |
$416.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$468.00
|
| Rate for Payer: Humana ChoiceCare |
$135.20
|
| Rate for Payer: Multiplan All |
$473.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$312.00
|
| Rate for Payer: OMNI Networks Commercial |
$364.00
|
| Rate for Payer: One Health Plan PPO/POS |
$468.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$494.00
|
| Rate for Payer: Three Rivers Provider Network All |
$390.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$457.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$130.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$483.60
|
| Rate for Payer: Zelis Auto |
$208.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$260.00
|
|
|
IMPLT PROSTHESIS SHOE GOLDENBURG
|
Facility
|
IP
|
$1,541.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$616.40 |
| Max. Negotiated Rate |
$1,463.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,232.80
|
| Rate for Payer: Cash Price |
$924.60
|
| Rate for Payer: Cash Price |
$924.60
|
| Rate for Payer: Cigna Commercial |
$1,309.85
|
| Rate for Payer: First Health Commercial |
$1,386.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,386.90
|
| Rate for Payer: GEHA Commercial |
$1,078.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,386.90
|
| Rate for Payer: Multiplan All |
$1,402.31
|
| Rate for Payer: OMNI Networks Commercial |
$1,078.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,386.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,463.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,155.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,433.13
|
| Rate for Payer: Zelis Auto |
$616.40
|
|
|
IMPLT PROSTHESIS SHOE GOLDENBURG
|
Facility
|
OP
|
$1,541.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006542
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$385.25 |
| Max. Negotiated Rate |
$1,463.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$924.60
|
| Rate for Payer: Cash Price |
$924.60
|
| Rate for Payer: Cash Price |
$924.60
|
| Rate for Payer: Cigna Commercial |
$1,309.85
|
| Rate for Payer: First Health Commercial |
$1,386.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,386.90
|
| Rate for Payer: GEHA Commercial |
$1,232.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,386.90
|
| Rate for Payer: Humana ChoiceCare |
$400.66
|
| Rate for Payer: Multiplan All |
$1,402.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$924.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,078.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,386.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,463.95
|
| Rate for Payer: Three Rivers Provider Network All |
$1,155.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,356.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$385.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,433.13
|
| Rate for Payer: Zelis Auto |
$616.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$770.50
|
|
|
IMPLT PROSTHESIS SMALL INCUDOSTAPEDIAL
|
Facility
|
OP
|
$2,243.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$560.75 |
| Max. Negotiated Rate |
$2,130.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,345.80
|
| Rate for Payer: Cash Price |
$1,345.80
|
| Rate for Payer: Cash Price |
$1,345.80
|
| Rate for Payer: Cigna Commercial |
$1,906.55
|
| Rate for Payer: First Health Commercial |
$2,018.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,018.70
|
| Rate for Payer: GEHA Commercial |
$1,794.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,018.70
|
| Rate for Payer: Humana ChoiceCare |
$583.18
|
| Rate for Payer: Multiplan All |
$2,041.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,345.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,570.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,018.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,130.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,682.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,973.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$560.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,085.99
|
| Rate for Payer: Zelis Auto |
$897.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,121.50
|
|
|
IMPLT PROSTHESIS SMALL INCUDOSTAPEDIAL
|
Facility
|
IP
|
$2,243.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.20 |
| Max. Negotiated Rate |
$2,130.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,794.40
|
| Rate for Payer: Cash Price |
$1,345.80
|
| Rate for Payer: Cash Price |
$1,345.80
|
| Rate for Payer: Cigna Commercial |
$1,906.55
|
| Rate for Payer: First Health Commercial |
$2,018.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,018.70
|
| Rate for Payer: GEHA Commercial |
$1,570.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,018.70
|
| Rate for Payer: Multiplan All |
$2,041.13
|
| Rate for Payer: OMNI Networks Commercial |
$1,570.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,018.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,130.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,682.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,085.99
|
| Rate for Payer: Zelis Auto |
$897.20
|
|
|
IMPLT PROSTHESIS TESTICULAR LRG SALINE-F
|
Facility
|
IP
|
$6,461.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003167
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,584.40 |
| Max. Negotiated Rate |
$6,137.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,168.80
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cigna Commercial |
$5,491.85
|
| Rate for Payer: First Health Commercial |
$5,814.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,814.90
|
| Rate for Payer: GEHA Commercial |
$4,522.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,814.90
|
| Rate for Payer: Multiplan All |
$5,879.51
|
| Rate for Payer: OMNI Networks Commercial |
$4,522.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,814.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,137.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,845.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,008.73
|
| Rate for Payer: Zelis Auto |
$2,584.40
|
|
|
IMPLT PROSTHESIS TESTICULAR LRG SALINE-F
|
Facility
|
OP
|
$6,461.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003167
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,615.25 |
| Max. Negotiated Rate |
$6,137.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cigna Commercial |
$5,491.85
|
| Rate for Payer: First Health Commercial |
$5,814.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,814.90
|
| Rate for Payer: GEHA Commercial |
$5,168.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,814.90
|
| Rate for Payer: Humana ChoiceCare |
$1,679.86
|
| Rate for Payer: Multiplan All |
$5,879.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,876.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,522.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,814.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,137.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,845.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,685.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,615.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,008.73
|
| Rate for Payer: Zelis Auto |
$2,584.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,230.50
|
|
|
IMPLT PROSTHESIS TESTICULAR MED SALINE-F
|
Facility
|
OP
|
$6,461.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,615.25 |
| Max. Negotiated Rate |
$6,137.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cigna Commercial |
$5,491.85
|
| Rate for Payer: First Health Commercial |
$5,814.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,814.90
|
| Rate for Payer: GEHA Commercial |
$5,168.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,814.90
|
| Rate for Payer: Humana ChoiceCare |
$1,679.86
|
| Rate for Payer: Multiplan All |
$5,879.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,876.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,522.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,814.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,137.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,845.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,685.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,615.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,008.73
|
| Rate for Payer: Zelis Auto |
$2,584.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,230.50
|
|
|
IMPLT PROSTHESIS TESTICULAR MED SALINE-F
|
Facility
|
IP
|
$6,461.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,584.40 |
| Max. Negotiated Rate |
$6,137.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,168.80
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cash Price |
$3,876.60
|
| Rate for Payer: Cigna Commercial |
$5,491.85
|
| Rate for Payer: First Health Commercial |
$5,814.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,814.90
|
| Rate for Payer: GEHA Commercial |
$4,522.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,814.90
|
| Rate for Payer: Multiplan All |
$5,879.51
|
| Rate for Payer: OMNI Networks Commercial |
$4,522.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,814.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,137.95
|
| Rate for Payer: Three Rivers Provider Network All |
$4,845.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,008.73
|
| Rate for Payer: Zelis Auto |
$2,584.40
|
|
|
IMPLT PROSTHESIS TORP GOLDENBURG 0.8X8MM
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$986.40 |
| Max. Negotiated Rate |
$2,342.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,972.80
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cigna Commercial |
$2,096.10
|
| Rate for Payer: First Health Commercial |
$2,219.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,219.40
|
| Rate for Payer: GEHA Commercial |
$1,726.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,219.40
|
| Rate for Payer: Multiplan All |
$2,244.06
|
| Rate for Payer: OMNI Networks Commercial |
$1,726.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,219.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,342.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,849.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,293.38
|
| Rate for Payer: Zelis Auto |
$986.40
|
|
|
IMPLT PROSTHESIS TORP GOLDENBURG 0.8X8MM
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006540
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$616.50 |
| Max. Negotiated Rate |
$2,342.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,479.60
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cigna Commercial |
$2,096.10
|
| Rate for Payer: First Health Commercial |
$2,219.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,219.40
|
| Rate for Payer: GEHA Commercial |
$1,972.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,219.40
|
| Rate for Payer: Humana ChoiceCare |
$641.16
|
| Rate for Payer: Multiplan All |
$2,244.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,479.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,726.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,219.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,342.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,849.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,170.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$616.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,293.38
|
| Rate for Payer: Zelis Auto |
$986.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,233.00
|
|
|
IMPLT PROSTH PHALANGEAL ANATOEMIC 17MM
|
Facility
|
IP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,514.00 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,028.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$2,649.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
|
|
IMPLT PROSTH PHALANGEAL ANATOEMIC 17MM
|
Facility
|
OP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$946.25 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$3,028.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Humana ChoiceCare |
$984.10
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,271.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,330.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$946.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,892.50
|
|
|
IMPLT PROSTH PHALANGEAL ANATOEMIC 18.5MM
|
Facility
|
OP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003119
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$946.25 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$3,028.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Humana ChoiceCare |
$984.10
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,271.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,330.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$946.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,892.50
|
|
|
IMPLT PROSTH PHALANGEAL ANATOEMIC 18.5MM
|
Facility
|
IP
|
$3,785.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003119
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,514.00 |
| Max. Negotiated Rate |
$3,595.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,028.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,217.25
|
| Rate for Payer: First Health Commercial |
$3,406.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,406.50
|
| Rate for Payer: GEHA Commercial |
$2,649.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,406.50
|
| Rate for Payer: Multiplan All |
$3,444.35
|
| Rate for Payer: OMNI Networks Commercial |
$2,649.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,406.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,595.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,838.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,520.05
|
| Rate for Payer: Zelis Auto |
$1,514.00
|
|
|
IMPLT PRO-STIM INJECTABLE
|
Facility
|
IP
|
$7,746.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,098.40 |
| Max. Negotiated Rate |
$7,358.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,196.80
|
| Rate for Payer: Cash Price |
$4,647.60
|
| Rate for Payer: Cash Price |
$4,647.60
|
| Rate for Payer: Cigna Commercial |
$6,584.10
|
| Rate for Payer: First Health Commercial |
$6,971.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,971.40
|
| Rate for Payer: GEHA Commercial |
$5,422.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,971.40
|
| Rate for Payer: Multiplan All |
$7,048.86
|
| Rate for Payer: OMNI Networks Commercial |
$5,422.20
|
| Rate for Payer: One Health Plan PPO/POS |
$6,971.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,358.70
|
| Rate for Payer: Three Rivers Provider Network All |
$5,809.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,203.78
|
| Rate for Payer: Zelis Auto |
$3,098.40
|
|
|
IMPLT PRO-STIM INJECTABLE
|
Facility
|
OP
|
$7,746.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,936.50 |
| Max. Negotiated Rate |
$7,358.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,647.60
|
| Rate for Payer: Cash Price |
$4,647.60
|
| Rate for Payer: Cash Price |
$4,647.60
|
| Rate for Payer: Cigna Commercial |
$6,584.10
|
| Rate for Payer: First Health Commercial |
$6,971.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,971.40
|
| Rate for Payer: GEHA Commercial |
$6,196.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,971.40
|
| Rate for Payer: Humana ChoiceCare |
$2,013.96
|
| Rate for Payer: Multiplan All |
$7,048.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,647.60
|
| Rate for Payer: OMNI Networks Commercial |
$5,422.20
|
| Rate for Payer: One Health Plan PPO/POS |
$6,971.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,358.70
|
| Rate for Payer: Three Rivers Provider Network All |
$5,809.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,816.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,936.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,203.78
|
| Rate for Payer: Zelis Auto |
$3,098.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,873.00
|
|
|
IMPLT PRO-STOP 10X14MM
|
Facility
|
OP
|
$4,263.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.75 |
| Max. Negotiated Rate |
$4,049.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,557.80
|
| Rate for Payer: Cash Price |
$2,557.80
|
| Rate for Payer: Cash Price |
$2,557.80
|
| Rate for Payer: Cigna Commercial |
$3,623.55
|
| Rate for Payer: First Health Commercial |
$3,836.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,836.70
|
| Rate for Payer: GEHA Commercial |
$3,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,836.70
|
| Rate for Payer: Humana ChoiceCare |
$1,108.38
|
| Rate for Payer: Multiplan All |
$3,879.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,557.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,984.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,836.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,049.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,197.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,751.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,065.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,964.59
|
| Rate for Payer: Zelis Auto |
$1,705.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,131.50
|
|
|
IMPLT PRO-STOP 10X14MM
|
Facility
|
IP
|
$4,263.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,705.20 |
| Max. Negotiated Rate |
$4,049.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,410.40
|
| Rate for Payer: Cash Price |
$2,557.80
|
| Rate for Payer: Cash Price |
$2,557.80
|
| Rate for Payer: Cigna Commercial |
$3,623.55
|
| Rate for Payer: First Health Commercial |
$3,836.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,836.70
|
| Rate for Payer: GEHA Commercial |
$2,984.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,836.70
|
| Rate for Payer: Multiplan All |
$3,879.33
|
| Rate for Payer: OMNI Networks Commercial |
$2,984.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,836.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,049.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,197.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,964.59
|
| Rate for Payer: Zelis Auto |
$1,705.20
|
|
|
IMPLT PRO STOP GUIDE PIN
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001233
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$107.75 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$258.60
|
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cash Price |
$258.60
|
| Rate for Payer: Cigna Commercial |
$366.35
|
| Rate for Payer: First Health Commercial |
$387.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$387.90
|
| Rate for Payer: GEHA Commercial |
$344.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Humana ChoiceCare |
$112.06
|
| Rate for Payer: Multiplan All |
$392.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$258.60
|
| Rate for Payer: OMNI Networks Commercial |
$301.70
|
| Rate for Payer: One Health Plan PPO/POS |
$387.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$409.45
|
| Rate for Payer: Three Rivers Provider Network All |
$323.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$379.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$107.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$215.50
|
|
