|
IMPLT PUMP PRECONNECT 700CX
|
Facility
|
IP
|
$25,777.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002392
|
|
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 PRECONNECT 700CX
|
Facility
|
OP
|
$25,777.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002392
|
|
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 PRE-CONNECT 700 LGX12
|
Facility
|
IP
|
$6,793.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,717.20 |
| Max. Negotiated Rate |
$6,453.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,434.40
|
| Rate for Payer: Cash Price |
$4,075.80
|
| Rate for Payer: Cash Price |
$4,075.80
|
| Rate for Payer: Cigna Commercial |
$5,774.05
|
| Rate for Payer: First Health Commercial |
$6,113.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,113.70
|
| Rate for Payer: GEHA Commercial |
$4,755.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,113.70
|
| Rate for Payer: Multiplan All |
$6,181.63
|
| Rate for Payer: OMNI Networks Commercial |
$4,755.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,113.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,453.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,094.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,317.49
|
| Rate for Payer: Zelis Auto |
$2,717.20
|
|
|
IMPLT PUMP PRE-CONNECT 700 LGX12
|
Facility
|
OP
|
$6,793.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7006390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,698.25 |
| Max. Negotiated Rate |
$6,453.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,075.80
|
| Rate for Payer: Cash Price |
$4,075.80
|
| Rate for Payer: Cash Price |
$4,075.80
|
| Rate for Payer: Cigna Commercial |
$5,774.05
|
| Rate for Payer: First Health Commercial |
$6,113.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,113.70
|
| Rate for Payer: GEHA Commercial |
$5,434.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,113.70
|
| Rate for Payer: Humana ChoiceCare |
$1,766.18
|
| Rate for Payer: Multiplan All |
$6,181.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,075.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,755.10
|
| Rate for Payer: One Health Plan PPO/POS |
$6,113.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,453.35
|
| Rate for Payer: Three Rivers Provider Network All |
$5,094.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,977.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,698.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,317.49
|
| Rate for Payer: Zelis Auto |
$2,717.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,396.50
|
|
|
IMPLT PUMP PRECONNECT 700 LGX MS
|
Facility
|
OP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002389
|
|
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
|
|
|
IMPLT PUMP PRECONNECT 700 LGX MS
|
Facility
|
IP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002389
|
|
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 PRECONNECT LGX 15CMX12MM
|
Facility
|
IP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002473
|
|
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 PRECONNECT LGX 15CMX12MM
|
Facility
|
OP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002473
|
|
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
|
|
|
IMPLT PUMP PRECONNECT LGX MS 18CM,IZ
|
Facility
|
IP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002391
|
|
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 PRECONNECT LGX MS 18CM,IZ
|
Facility
|
OP
|
$26,248.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002391
|
|
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
|
|
|
IMPLT PURAPLY 1.6 DISC
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7006622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$274.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Humana ChoiceCare |
$118.82
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$274.20
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$402.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: Zelis Auto |
$182.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$228.50
|
|
|
IMPLT PURAPLY 1.6 DISC
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.77 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: First Health Workers Compensation |
$176.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$77.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Humana ChoiceCare |
$118.82
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$274.20
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$402.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$114.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: Zelis Auto |
$182.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$228.50
|
| Rate for Payer: Zelis Worker's Compensation |
$124.76
|
|
|
IMPLT PURAPLY 1.6 DISC
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$124.76 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: First Health Workers Compensation |
$176.45
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$319.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: Zelis Auto |
$182.80
|
| Rate for Payer: Zelis Worker's Compensation |
$124.76
|
|
|
IMPLT PURAPLY 1.6 DISC
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7006622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.80 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$365.60
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cash Price |
$274.20
|
| Rate for Payer: Cigna Commercial |
$388.45
|
| Rate for Payer: First Health Commercial |
$411.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$411.30
|
| Rate for Payer: GEHA Commercial |
$319.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$411.30
|
| Rate for Payer: Multiplan All |
$415.87
|
| Rate for Payer: OMNI Networks Commercial |
$319.90
|
| Rate for Payer: One Health Plan PPO/POS |
$411.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$434.15
|
| Rate for Payer: Three Rivers Provider Network All |
$342.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$425.01
|
| Rate for Payer: Zelis Auto |
$182.80
|
|
|
IMPLT PURAPLY 2X2
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003039
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$304.40 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$608.80
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$532.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
|
|
IMPLT PURAPLY 2X2
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003039
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$722.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$456.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cash Price |
$456.60
|
| Rate for Payer: Cigna Commercial |
$646.85
|
| Rate for Payer: First Health Commercial |
$684.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$684.90
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$684.90
|
| Rate for Payer: Humana ChoiceCare |
$197.86
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$692.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$456.60
|
| Rate for Payer: OMNI Networks Commercial |
$532.70
|
| Rate for Payer: One Health Plan PPO/POS |
$684.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$722.95
|
| Rate for Payer: Three Rivers Provider Network All |
$570.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$669.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$707.73
|
| Rate for Payer: Zelis Auto |
$304.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$380.50
|
|
|
IMPLT PURAPLY 2X4
|
Facility
|
OP
|
$2,487.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$2,362.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,492.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$1,492.20
|
| Rate for Payer: Cash Price |
$1,492.20
|
| Rate for Payer: Cash Price |
$1,492.20
|
| Rate for Payer: Cigna Commercial |
$2,113.95
|
| Rate for Payer: First Health Commercial |
$2,238.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,238.30
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,238.30
|
| Rate for Payer: Humana ChoiceCare |
$646.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$2,263.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,492.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,740.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,238.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,362.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,865.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,188.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,312.91
|
| Rate for Payer: Zelis Auto |
$994.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,243.50
|
|
|
IMPLT PURAPLY 2X4
|
Facility
|
IP
|
$2,487.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$994.80 |
| Max. Negotiated Rate |
$2,362.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,989.60
|
| Rate for Payer: Cash Price |
$1,492.20
|
| Rate for Payer: Cash Price |
$1,492.20
|
| Rate for Payer: Cigna Commercial |
$2,113.95
|
| Rate for Payer: First Health Commercial |
$2,238.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,238.30
|
| Rate for Payer: GEHA Commercial |
$1,740.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,238.30
|
| Rate for Payer: Multiplan All |
$2,263.17
|
| Rate for Payer: OMNI Networks Commercial |
$1,740.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,238.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,362.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,865.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,312.91
|
| Rate for Payer: Zelis Auto |
$994.80
|
|
|
IMPLT PURAPLY 4X4
|
Facility
|
OP
|
$6,029.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7004280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,617.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cigna Commercial |
$5,124.65
|
| Rate for Payer: First Health Commercial |
$5,426.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,426.10
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,426.10
|
| Rate for Payer: Humana ChoiceCare |
$1,567.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$5,486.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,617.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,220.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,426.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,727.55
|
| Rate for Payer: Three Rivers Provider Network All |
$4,521.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,305.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,606.97
|
| Rate for Payer: Zelis Auto |
$2,411.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,014.50
|
|
|
IMPLT PURAPLY 4X4
|
Facility
|
IP
|
$6,029.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7004280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,411.60 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,823.20
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cigna Commercial |
$5,124.65
|
| Rate for Payer: First Health Commercial |
$5,426.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,426.10
|
| Rate for Payer: GEHA Commercial |
$4,220.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,426.10
|
| Rate for Payer: Multiplan All |
$5,486.39
|
| Rate for Payer: OMNI Networks Commercial |
$4,220.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,426.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,727.55
|
| Rate for Payer: Three Rivers Provider Network All |
$4,521.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,606.97
|
| Rate for Payer: Zelis Auto |
$2,411.60
|
|
|
IMPLT PURAPLY 5X5
|
Facility
|
OP
|
$6,029.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,617.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cigna Commercial |
$5,124.65
|
| Rate for Payer: First Health Commercial |
$5,426.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,426.10
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,426.10
|
| Rate for Payer: Humana ChoiceCare |
$1,567.54
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$5,486.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,617.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,220.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,426.10
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,727.55
|
| Rate for Payer: Three Rivers Provider Network All |
$4,521.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,305.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,606.97
|
| Rate for Payer: Zelis Auto |
$2,411.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,014.50
|
|
|
IMPLT PURAPLY 5X5
|
Facility
|
IP
|
$6,029.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,411.60 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,823.20
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cash Price |
$3,617.40
|
| Rate for Payer: Cigna Commercial |
$5,124.65
|
| Rate for Payer: First Health Commercial |
$5,426.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,426.10
|
| Rate for Payer: GEHA Commercial |
$4,220.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,426.10
|
| Rate for Payer: Multiplan All |
$5,486.39
|
| Rate for Payer: OMNI Networks Commercial |
$4,220.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,426.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,727.55
|
| Rate for Payer: Three Rivers Provider Network All |
$4,521.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,606.97
|
| Rate for Payer: Zelis Auto |
$2,411.60
|
|
|
IMPLT PURAPLY 6X9
|
Facility
|
OP
|
$16,382.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003010
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$15,562.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,829.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$9,829.20
|
| Rate for Payer: Cash Price |
$9,829.20
|
| Rate for Payer: Cash Price |
$9,829.20
|
| Rate for Payer: Cigna Commercial |
$13,924.70
|
| Rate for Payer: First Health Commercial |
$14,743.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,743.80
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,743.80
|
| Rate for Payer: Humana ChoiceCare |
$4,259.32
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$14,907.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,829.20
|
| Rate for Payer: OMNI Networks Commercial |
$11,467.40
|
| Rate for Payer: One Health Plan PPO/POS |
$14,743.80
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,562.90
|
| Rate for Payer: Three Rivers Provider Network All |
$12,286.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14,416.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15,235.26
|
| Rate for Payer: Zelis Auto |
$6,552.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,191.00
|
|
|
IMPLT PURAPLY 6X9
|
Facility
|
IP
|
$16,382.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003010
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,552.80 |
| Max. Negotiated Rate |
$15,562.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$13,105.60
|
| Rate for Payer: Cash Price |
$9,829.20
|
| Rate for Payer: Cash Price |
$9,829.20
|
| Rate for Payer: Cigna Commercial |
$13,924.70
|
| Rate for Payer: First Health Commercial |
$14,743.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,743.80
|
| Rate for Payer: GEHA Commercial |
$11,467.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,743.80
|
| Rate for Payer: Multiplan All |
$14,907.62
|
| Rate for Payer: OMNI Networks Commercial |
$11,467.40
|
| Rate for Payer: One Health Plan PPO/POS |
$14,743.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,562.90
|
| Rate for Payer: Three Rivers Provider Network All |
$12,286.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15,235.26
|
| Rate for Payer: Zelis Auto |
$6,552.80
|
|
|
IMPLT PURAPLY 8X16
|
Facility
|
IP
|
$39,737.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003179
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,894.80 |
| Max. Negotiated Rate |
$37,750.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31,789.60
|
| Rate for Payer: Cash Price |
$23,842.20
|
| Rate for Payer: Cash Price |
$23,842.20
|
| Rate for Payer: Cigna Commercial |
$33,776.45
|
| Rate for Payer: First Health Commercial |
$35,763.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35,763.30
|
| Rate for Payer: GEHA Commercial |
$27,815.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35,763.30
|
| Rate for Payer: Multiplan All |
$36,160.67
|
| Rate for Payer: OMNI Networks Commercial |
$27,815.90
|
| Rate for Payer: One Health Plan PPO/POS |
$35,763.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37,750.15
|
| Rate for Payer: Three Rivers Provider Network All |
$29,802.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36,955.41
|
| Rate for Payer: Zelis Auto |
$15,894.80
|
|
