|
IMPLT SCR 3.5 CORT 32MM FINE THRD
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$37.44
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.40
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$126.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.00
|
|
|
IMPLT SCR 3.5 CORT 32MM FINE THRD
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
|
|
IMPLT SCR 3.5 CORTICAL 28MM
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$115.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Humana ChoiceCare |
$37.44
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$86.40
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$126.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$36.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$72.00
|
|
|
IMPLT SCR 3.5 CORTICAL 28MM
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$115.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$122.40
|
| Rate for Payer: First Health Commercial |
$129.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$129.60
|
| Rate for Payer: GEHA Commercial |
$100.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$129.60
|
| Rate for Payer: Multiplan All |
$131.04
|
| Rate for Payer: OMNI Networks Commercial |
$100.80
|
| Rate for Payer: One Health Plan PPO/POS |
$129.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$136.80
|
| Rate for Payer: Three Rivers Provider Network All |
$108.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$133.92
|
| Rate for Payer: Zelis Auto |
$57.60
|
|
|
IMPLT SCR 6.5X45MM PT CANN
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$89.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Humana ChoiceCare |
$29.12
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$67.20
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$98.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$28.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$56.00
|
|
|
IMPLT SCR 6.5X45MM PT CANN
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$89.60
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: First Health Commercial |
$100.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$100.80
|
| Rate for Payer: GEHA Commercial |
$78.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$100.80
|
| Rate for Payer: Multiplan All |
$101.92
|
| Rate for Payer: OMNI Networks Commercial |
$78.40
|
| Rate for Payer: One Health Plan PPO/POS |
$100.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$106.40
|
| Rate for Payer: Three Rivers Provider Network All |
$84.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$104.16
|
| Rate for Payer: Zelis Auto |
$44.80
|
|
|
IMPLT SCR ACUMED CANNULATED 2.7X12
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$284.40 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$568.80
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cigna Commercial |
$604.35
|
| Rate for Payer: First Health Commercial |
$639.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.90
|
| Rate for Payer: GEHA Commercial |
$497.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.90
|
| Rate for Payer: Multiplan All |
$647.01
|
| Rate for Payer: OMNI Networks Commercial |
$497.70
|
| Rate for Payer: One Health Plan PPO/POS |
$639.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$675.45
|
| Rate for Payer: Three Rivers Provider Network All |
$533.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$661.23
|
| Rate for Payer: Zelis Auto |
$284.40
|
|
|
IMPLT SCR ACUMED CANNULATED 2.7X12
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$177.75 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$426.60
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cash Price |
$426.60
|
| Rate for Payer: Cigna Commercial |
$604.35
|
| Rate for Payer: First Health Commercial |
$639.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$639.90
|
| Rate for Payer: GEHA Commercial |
$568.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$639.90
|
| Rate for Payer: Humana ChoiceCare |
$184.86
|
| Rate for Payer: Multiplan All |
$647.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$426.60
|
| Rate for Payer: OMNI Networks Commercial |
$497.70
|
| Rate for Payer: One Health Plan PPO/POS |
$639.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$675.45
|
| Rate for Payer: Three Rivers Provider Network All |
$533.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$625.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$177.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$661.23
|
| Rate for Payer: Zelis Auto |
$284.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$355.50
|
|
|
IMPLT SCR CTX 2.7MMX10MM EVOS T8 S-T
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.80
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
|
|
IMPLT SCR CTX 2.7MMX10MM EVOS T8 S-T
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
|
|
IMPLT SCR CTX 2.7MMX12MM EVOS
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$81.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Humana ChoiceCare |
$26.52
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$61.20
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$89.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$25.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: Zelis Auto |
$40.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$51.00
|
|
|
IMPLT SCR CTX 2.7MMX12MM EVOS
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$81.60
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$86.70
|
| Rate for Payer: First Health Commercial |
$91.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$91.80
|
| Rate for Payer: GEHA Commercial |
$71.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$91.80
|
| Rate for Payer: Multiplan All |
$92.82
|
| Rate for Payer: OMNI Networks Commercial |
$71.40
|
| Rate for Payer: One Health Plan PPO/POS |
$91.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$96.90
|
| Rate for Payer: Three Rivers Provider Network All |
$76.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$94.86
|
| Rate for Payer: Zelis Auto |
$40.80
|
|
|
IMPLT SCR CTX 2.7MMX14MM EVOS T8 S-T
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
|
|
IMPLT SCR CTX 2.7MMX14MM EVOS T8 S-T
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.80
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
|
|
IMPLT SCR CTX 3.5MMX12MM S-T EVOS
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003297
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$84.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Humana ChoiceCare |
$27.56
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.60
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$93.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$26.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$53.00
|
|
|
IMPLT SCR CTX 3.5MMX12MM S-T EVOS
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003297
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$84.80
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$90.10
|
| Rate for Payer: First Health Commercial |
$95.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$95.40
|
| Rate for Payer: GEHA Commercial |
$74.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$95.40
|
| Rate for Payer: Multiplan All |
$96.46
|
| Rate for Payer: OMNI Networks Commercial |
$74.20
|
| Rate for Payer: One Health Plan PPO/POS |
$95.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$100.70
|
| Rate for Payer: Three Rivers Provider Network All |
$79.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$98.58
|
| Rate for Payer: Zelis Auto |
$42.40
|
|
|
IMPLT SCREW 10X1.5MM
|
Facility
|
IP
|
$297.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$118.80 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$237.60
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cigna Commercial |
$252.45
|
| Rate for Payer: First Health Commercial |
$267.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$267.30
|
| Rate for Payer: GEHA Commercial |
$207.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$267.30
|
| Rate for Payer: Multiplan All |
$270.27
|
| Rate for Payer: OMNI Networks Commercial |
$207.90
|
| Rate for Payer: One Health Plan PPO/POS |
$267.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$282.15
|
| Rate for Payer: Three Rivers Provider Network All |
$222.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$276.21
|
| Rate for Payer: Zelis Auto |
$118.80
|
|
|
IMPLT SCREW 10X1.5MM
|
Facility
|
OP
|
$297.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$74.25 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$178.20
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cigna Commercial |
$252.45
|
| Rate for Payer: First Health Commercial |
$267.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$267.30
|
| Rate for Payer: GEHA Commercial |
$237.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$267.30
|
| Rate for Payer: Humana ChoiceCare |
$77.22
|
| Rate for Payer: Multiplan All |
$270.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$178.20
|
| Rate for Payer: OMNI Networks Commercial |
$207.90
|
| Rate for Payer: One Health Plan PPO/POS |
$267.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$282.15
|
| Rate for Payer: Three Rivers Provider Network All |
$222.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$261.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$276.21
|
| Rate for Payer: Zelis Auto |
$118.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$148.50
|
|
|
IMPLT SCREW 1.2MMX10
|
Facility
|
OP
|
$614.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$153.50 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cigna Commercial |
$521.90
|
| Rate for Payer: First Health Commercial |
$552.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$552.60
|
| Rate for Payer: GEHA Commercial |
$491.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$552.60
|
| Rate for Payer: Humana ChoiceCare |
$159.64
|
| Rate for Payer: Multiplan All |
$558.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$368.40
|
| Rate for Payer: OMNI Networks Commercial |
$429.80
|
| Rate for Payer: One Health Plan PPO/POS |
$552.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$583.30
|
| Rate for Payer: Three Rivers Provider Network All |
$460.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$540.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$153.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$571.02
|
| Rate for Payer: Zelis Auto |
$245.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$307.00
|
|
|
IMPLT SCREW 1.2MMX10
|
Facility
|
IP
|
$614.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.60 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$491.20
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cigna Commercial |
$521.90
|
| Rate for Payer: First Health Commercial |
$552.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$552.60
|
| Rate for Payer: GEHA Commercial |
$429.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$552.60
|
| Rate for Payer: Multiplan All |
$558.74
|
| Rate for Payer: OMNI Networks Commercial |
$429.80
|
| Rate for Payer: One Health Plan PPO/POS |
$552.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$583.30
|
| Rate for Payer: Three Rivers Provider Network All |
$460.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$571.02
|
| Rate for Payer: Zelis Auto |
$245.60
|
|
|
IMPLT SCREW 1.2MMX8
|
Facility
|
OP
|
$614.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000441
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$153.50 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cigna Commercial |
$521.90
|
| Rate for Payer: First Health Commercial |
$552.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$552.60
|
| Rate for Payer: GEHA Commercial |
$491.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$552.60
|
| Rate for Payer: Humana ChoiceCare |
$159.64
|
| Rate for Payer: Multiplan All |
$558.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$368.40
|
| Rate for Payer: OMNI Networks Commercial |
$429.80
|
| Rate for Payer: One Health Plan PPO/POS |
$552.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$583.30
|
| Rate for Payer: Three Rivers Provider Network All |
$460.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$540.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$153.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$571.02
|
| Rate for Payer: Zelis Auto |
$245.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$307.00
|
|
|
IMPLT SCREW 1.2MMX8
|
Facility
|
IP
|
$614.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000441
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.60 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$491.20
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cash Price |
$368.40
|
| Rate for Payer: Cigna Commercial |
$521.90
|
| Rate for Payer: First Health Commercial |
$552.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$552.60
|
| Rate for Payer: GEHA Commercial |
$429.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$552.60
|
| Rate for Payer: Multiplan All |
$558.74
|
| Rate for Payer: OMNI Networks Commercial |
$429.80
|
| Rate for Payer: One Health Plan PPO/POS |
$552.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$583.30
|
| Rate for Payer: Three Rivers Provider Network All |
$460.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$571.02
|
| Rate for Payer: Zelis Auto |
$245.60
|
|
|
IMPLT SCREW 1/2 THREAD 40MM
|
Facility
|
OP
|
$987.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.75 |
| Max. Negotiated Rate |
$937.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cigna Commercial |
$838.95
|
| Rate for Payer: First Health Commercial |
$888.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$888.30
|
| Rate for Payer: GEHA Commercial |
$789.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$888.30
|
| Rate for Payer: Humana ChoiceCare |
$256.62
|
| Rate for Payer: Multiplan All |
$898.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$592.20
|
| Rate for Payer: OMNI Networks Commercial |
$690.90
|
| Rate for Payer: One Health Plan PPO/POS |
$888.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$937.65
|
| Rate for Payer: Three Rivers Provider Network All |
$740.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$868.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$246.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$917.91
|
| Rate for Payer: Zelis Auto |
$394.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$493.50
|
|
|
IMPLT SCREW 1/2 THREAD 40MM
|
Facility
|
IP
|
$987.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$394.80 |
| Max. Negotiated Rate |
$937.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$789.60
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cigna Commercial |
$838.95
|
| Rate for Payer: First Health Commercial |
$888.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$888.30
|
| Rate for Payer: GEHA Commercial |
$690.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$888.30
|
| Rate for Payer: Multiplan All |
$898.17
|
| Rate for Payer: OMNI Networks Commercial |
$690.90
|
| Rate for Payer: One Health Plan PPO/POS |
$888.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$937.65
|
| Rate for Payer: Three Rivers Provider Network All |
$740.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$917.91
|
| Rate for Payer: Zelis Auto |
$394.80
|
|
|
IMPLT SCREW 1/2 THREAD 42MM
|
Facility
|
OP
|
$987.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.75 |
| Max. Negotiated Rate |
$937.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cigna Commercial |
$838.95
|
| Rate for Payer: First Health Commercial |
$888.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$888.30
|
| Rate for Payer: GEHA Commercial |
$789.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$888.30
|
| Rate for Payer: Humana ChoiceCare |
$256.62
|
| Rate for Payer: Multiplan All |
$898.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$592.20
|
| Rate for Payer: OMNI Networks Commercial |
$690.90
|
| Rate for Payer: One Health Plan PPO/POS |
$888.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$937.65
|
| Rate for Payer: Three Rivers Provider Network All |
$740.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$868.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$246.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$917.91
|
| Rate for Payer: Zelis Auto |
$394.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$493.50
|
|
