|
IMPLT PRO STOP GUIDE PIN
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001233
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$172.40 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$344.80
|
| 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 |
$301.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$387.90
|
| Rate for Payer: Multiplan All |
$392.21
|
| 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: United Payors & United Providers UP&UP |
$400.83
|
| Rate for Payer: Zelis Auto |
$172.40
|
|
|
IMPLT PRO-STOP STJ 11X16MM
|
Facility
|
OP
|
$4,263.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006392
|
|
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 STJ 11X16MM
|
Facility
|
IP
|
$4,263.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006392
|
|
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 PROTECTOR NERVE PERIPHERAL 10X40MM
|
Facility
|
IP
|
$7,613.00
|
|
|
Service Code
|
CPT C9355
|
| Hospital Charge Code |
7006534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,045.20 |
| Max. Negotiated Rate |
$7,232.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,090.40
|
| Rate for Payer: Cash Price |
$4,567.80
|
| Rate for Payer: Cash Price |
$4,567.80
|
| Rate for Payer: Cigna Commercial |
$6,471.05
|
| Rate for Payer: First Health Commercial |
$6,851.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,851.70
|
| Rate for Payer: GEHA Commercial |
$5,329.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,851.70
|
| Rate for Payer: Multiplan All |
$6,927.83
|
| Rate for Payer: OMNI Networks Commercial |
$5,329.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,851.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,232.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,709.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,080.09
|
| Rate for Payer: Zelis Auto |
$3,045.20
|
|
|
IMPLT PROTECTOR NERVE PERIPHERAL 10X40MM
|
Facility
|
OP
|
$7,613.00
|
|
|
Service Code
|
CPT C9355
|
| Hospital Charge Code |
7006534
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,903.25 |
| Max. Negotiated Rate |
$7,232.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,567.80
|
| Rate for Payer: Cash Price |
$4,567.80
|
| Rate for Payer: Cash Price |
$4,567.80
|
| Rate for Payer: Cigna Commercial |
$6,471.05
|
| Rate for Payer: First Health Commercial |
$6,851.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,851.70
|
| Rate for Payer: GEHA Commercial |
$6,090.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,851.70
|
| Rate for Payer: Humana ChoiceCare |
$1,979.38
|
| Rate for Payer: Multiplan All |
$6,927.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,567.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,329.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,851.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,232.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,709.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,699.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,903.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,080.09
|
| Rate for Payer: Zelis Auto |
$3,045.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,806.50
|
|
|
IMPLT PROTHESIS LARGE INCUDOSTAPEDIAL
|
Facility
|
IP
|
$2,243.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002129
|
|
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 PROTHESIS LARGE INCUDOSTAPEDIAL
|
Facility
|
OP
|
$2,243.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002129
|
|
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 PT SCREW 121854
|
Facility
|
IP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.00 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$844.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$738.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
|
|
IMPLT PT SCREW 121854
|
Facility
|
OP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.75 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$844.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Humana ChoiceCare |
$274.30
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$633.00
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$928.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$527.50
|
|
|
IMPLT PT SCREW 121856
|
Facility
|
OP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.75 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$844.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Humana ChoiceCare |
$274.30
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$633.00
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$928.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$527.50
|
|
|
IMPLT PT SCREW 121856
|
Facility
|
IP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001235
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.00 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$844.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$738.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
|
|
IMPLT PT SCREW 121860
|
Facility
|
OP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001236
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.75 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$844.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Humana ChoiceCare |
$274.30
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$633.00
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$928.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$527.50
|
|
|
IMPLT PT SCREW 121860
|
Facility
|
IP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001236
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.00 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$844.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$738.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
|
|
IMPLT PUMP AND CYLINDER CX 700 AMS
|
Facility
|
IP
|
$25,777.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,310.80 |
| Max. Negotiated Rate |
$24,488.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20,621.60
|
| Rate for Payer: Cash Price |
$15,466.20
|
| Rate for Payer: Cash Price |
$15,466.20
|
| Rate for Payer: Cigna Commercial |
$21,910.45
|
| Rate for Payer: First Health Commercial |
$23,199.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,199.30
|
| Rate for Payer: GEHA Commercial |
$18,043.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,199.30
|
| Rate for Payer: Multiplan All |
$23,457.07
|
| Rate for Payer: OMNI Networks Commercial |
$18,043.90
|
| Rate for Payer: One Health Plan PPO/POS |
$23,199.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,488.15
|
| Rate for Payer: Three Rivers Provider Network All |
$19,332.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23,972.61
|
| Rate for Payer: Zelis Auto |
$10,310.80
|
|
|
IMPLT PUMP AND CYLINDER CX 700 AMS
|
Facility
|
OP
|
$25,777.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,444.25 |
| Max. Negotiated Rate |
$24,488.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,466.20
|
| Rate for Payer: Cash Price |
$15,466.20
|
| Rate for Payer: Cash Price |
$15,466.20
|
| Rate for Payer: Cigna Commercial |
$21,910.45
|
| Rate for Payer: First Health Commercial |
$23,199.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,199.30
|
| Rate for Payer: GEHA Commercial |
$20,621.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,199.30
|
| Rate for Payer: Humana ChoiceCare |
$6,702.02
|
| Rate for Payer: Multiplan All |
$23,457.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15,466.20
|
| Rate for Payer: OMNI Networks Commercial |
$18,043.90
|
| Rate for Payer: One Health Plan PPO/POS |
$23,199.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,488.15
|
| Rate for Payer: Three Rivers Provider Network All |
$19,332.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22,683.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,444.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23,972.61
|
| Rate for Payer: Zelis Auto |
$10,310.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12,888.50
|
|
|
IMPLT PUMP AND CYLINDERS 700 AMS
|
Facility
|
OP
|
$25,478.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006353
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,369.50 |
| Max. Negotiated Rate |
$24,204.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,286.80
|
| Rate for Payer: Cash Price |
$15,286.80
|
| Rate for Payer: Cash Price |
$15,286.80
|
| Rate for Payer: Cigna Commercial |
$21,656.30
|
| Rate for Payer: First Health Commercial |
$22,930.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22,930.20
|
| Rate for Payer: GEHA Commercial |
$20,382.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22,930.20
|
| Rate for Payer: Humana ChoiceCare |
$6,624.28
|
| Rate for Payer: Multiplan All |
$23,184.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15,286.80
|
| Rate for Payer: OMNI Networks Commercial |
$17,834.60
|
| Rate for Payer: One Health Plan PPO/POS |
$22,930.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,204.10
|
| Rate for Payer: Three Rivers Provider Network All |
$19,108.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$22,420.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,369.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23,694.54
|
| Rate for Payer: Zelis Auto |
$10,191.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$12,739.00
|
|
|
IMPLT PUMP AND CYLINDERS 700 AMS
|
Facility
|
IP
|
$25,478.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006353
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,191.20 |
| Max. Negotiated Rate |
$24,204.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20,382.40
|
| Rate for Payer: Cash Price |
$15,286.80
|
| Rate for Payer: Cash Price |
$15,286.80
|
| Rate for Payer: Cigna Commercial |
$21,656.30
|
| Rate for Payer: First Health Commercial |
$22,930.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$22,930.20
|
| Rate for Payer: GEHA Commercial |
$17,834.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$22,930.20
|
| Rate for Payer: Multiplan All |
$23,184.98
|
| Rate for Payer: OMNI Networks Commercial |
$17,834.60
|
| Rate for Payer: One Health Plan PPO/POS |
$22,930.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,204.10
|
| Rate for Payer: Three Rivers Provider Network All |
$19,108.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$23,694.54
|
| Rate for Payer: Zelis Auto |
$10,191.20
|
|
|
IMPLT PUMP AND CYLINDERS LGX 700 AMS
|
Facility
|
OP
|
$28,620.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,155.00 |
| Max. Negotiated Rate |
$27,189.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17,172.00
|
| Rate for Payer: Cash Price |
$17,172.00
|
| Rate for Payer: Cash Price |
$17,172.00
|
| Rate for Payer: Cigna Commercial |
$24,327.00
|
| Rate for Payer: First Health Commercial |
$25,758.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25,758.00
|
| Rate for Payer: GEHA Commercial |
$22,896.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25,758.00
|
| Rate for Payer: Humana ChoiceCare |
$7,441.20
|
| Rate for Payer: Multiplan All |
$26,044.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$17,172.00
|
| Rate for Payer: OMNI Networks Commercial |
$20,034.00
|
| Rate for Payer: One Health Plan PPO/POS |
$25,758.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27,189.00
|
| Rate for Payer: Three Rivers Provider Network All |
$21,465.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$25,185.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7,155.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26,616.60
|
| Rate for Payer: Zelis Auto |
$11,448.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$14,310.00
|
|
|
IMPLT PUMP AND CYLINDERS LGX 700 AMS
|
Facility
|
IP
|
$28,620.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,448.00 |
| Max. Negotiated Rate |
$27,189.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22,896.00
|
| Rate for Payer: Cash Price |
$17,172.00
|
| Rate for Payer: Cash Price |
$17,172.00
|
| Rate for Payer: Cigna Commercial |
$24,327.00
|
| Rate for Payer: First Health Commercial |
$25,758.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$25,758.00
|
| Rate for Payer: GEHA Commercial |
$20,034.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$25,758.00
|
| Rate for Payer: Multiplan All |
$26,044.20
|
| Rate for Payer: OMNI Networks Commercial |
$20,034.00
|
| Rate for Payer: One Health Plan PPO/POS |
$25,758.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$27,189.00
|
| Rate for Payer: Three Rivers Provider Network All |
$21,465.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$26,616.60
|
| Rate for Payer: Zelis Auto |
$11,448.00
|
|
|
IMPLT PUMP CONTROL AMS 800
|
Facility
|
IP
|
$17,347.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,938.80 |
| Max. Negotiated Rate |
$16,479.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13,877.60
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cigna Commercial |
$14,744.95
|
| Rate for Payer: First Health Commercial |
$15,612.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,612.30
|
| Rate for Payer: GEHA Commercial |
$12,142.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,612.30
|
| Rate for Payer: Multiplan All |
$15,785.77
|
| Rate for Payer: OMNI Networks Commercial |
$12,142.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15,612.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,479.65
|
| Rate for Payer: Three Rivers Provider Network All |
$13,010.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,132.71
|
| Rate for Payer: Zelis Auto |
$6,938.80
|
|
|
IMPLT PUMP CONTROL AMS 800
|
Facility
|
OP
|
$17,347.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,336.75 |
| Max. Negotiated Rate |
$16,479.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cigna Commercial |
$14,744.95
|
| Rate for Payer: First Health Commercial |
$15,612.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,612.30
|
| Rate for Payer: GEHA Commercial |
$13,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,612.30
|
| Rate for Payer: Humana ChoiceCare |
$4,510.22
|
| Rate for Payer: Multiplan All |
$15,785.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,408.20
|
| Rate for Payer: OMNI Networks Commercial |
$12,142.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15,612.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,479.65
|
| Rate for Payer: Three Rivers Provider Network All |
$13,010.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15,265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,336.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,132.71
|
| Rate for Payer: Zelis Auto |
$6,938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,673.50
|
|
|
IMPLT PUMP,CONTROL AMS 800
|
Facility
|
IP
|
$17,347.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
90000177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,938.80 |
| Max. Negotiated Rate |
$16,479.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13,877.60
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cigna Commercial |
$14,744.95
|
| Rate for Payer: First Health Commercial |
$15,612.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,612.30
|
| Rate for Payer: GEHA Commercial |
$12,142.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,612.30
|
| Rate for Payer: Multiplan All |
$15,785.77
|
| Rate for Payer: OMNI Networks Commercial |
$12,142.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15,612.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,479.65
|
| Rate for Payer: Three Rivers Provider Network All |
$13,010.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,132.71
|
| Rate for Payer: Zelis Auto |
$6,938.80
|
|
|
IMPLT PUMP,CONTROL AMS 800
|
Facility
|
OP
|
$17,347.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
90000177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,336.75 |
| Max. Negotiated Rate |
$16,479.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cash Price |
$10,408.20
|
| Rate for Payer: Cigna Commercial |
$14,744.95
|
| Rate for Payer: First Health Commercial |
$15,612.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,612.30
|
| Rate for Payer: GEHA Commercial |
$13,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,612.30
|
| Rate for Payer: Humana ChoiceCare |
$4,510.22
|
| Rate for Payer: Multiplan All |
$15,785.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,408.20
|
| Rate for Payer: OMNI Networks Commercial |
$12,142.90
|
| Rate for Payer: One Health Plan PPO/POS |
$15,612.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,479.65
|
| Rate for Payer: Three Rivers Provider Network All |
$13,010.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$15,265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,336.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,132.71
|
| Rate for Payer: Zelis Auto |
$6,938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,673.50
|
|
|
IMPLT PUMP MS LGX 700 18CMX12MM IZ
|
Facility
|
IP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,499.20 |
| Max. Negotiated Rate |
$24,935.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$20,998.40
|
| Rate for Payer: Cash Price |
$15,748.80
|
| Rate for Payer: Cash Price |
$15,748.80
|
| Rate for Payer: Cigna Commercial |
$22,310.80
|
| Rate for Payer: First Health Commercial |
$23,623.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,623.20
|
| Rate for Payer: GEHA Commercial |
$18,373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,623.20
|
| Rate for Payer: Multiplan All |
$23,885.68
|
| Rate for Payer: OMNI Networks Commercial |
$18,373.60
|
| Rate for Payer: One Health Plan PPO/POS |
$23,623.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,935.60
|
| Rate for Payer: Three Rivers Provider Network All |
$19,686.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24,410.64
|
| Rate for Payer: Zelis Auto |
$10,499.20
|
|
|
IMPLT PUMP MS LGX 700 18CMX12MM IZ
|
Facility
|
OP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7003002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,562.00 |
| Max. Negotiated Rate |
$24,935.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,748.80
|
| Rate for Payer: Cash Price |
$15,748.80
|
| Rate for Payer: Cash Price |
$15,748.80
|
| Rate for Payer: Cigna Commercial |
$22,310.80
|
| Rate for Payer: First Health Commercial |
$23,623.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$23,623.20
|
| Rate for Payer: GEHA Commercial |
$20,998.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$23,623.20
|
| Rate for Payer: Humana ChoiceCare |
$6,824.48
|
| Rate for Payer: Multiplan All |
$23,885.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$15,748.80
|
| Rate for Payer: OMNI Networks Commercial |
$18,373.60
|
| Rate for Payer: One Health Plan PPO/POS |
$23,623.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$24,935.60
|
| Rate for Payer: Three Rivers Provider Network All |
$19,686.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$23,098.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$6,562.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$24,410.64
|
| Rate for Payer: Zelis Auto |
$10,499.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13,124.00
|
|
