|
IMPLT SCR LCK 3.5MMX10MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR LCK 3.5MMX10MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003300
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX11MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR LCK 3.5MMX11MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX12MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR LCK 3.5MMX12MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX13MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX13MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR LCK 3.5MMX14MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX14MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003366
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR LCK 3.5MMX16MM EVOS S-T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003367
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.80 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$373.60
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$326.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
|
|
IMPLT SCR LCK 3.5MMX16MM EVOS S-T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003367
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.75 |
| Max. Negotiated Rate |
$443.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$396.95
|
| Rate for Payer: First Health Commercial |
$420.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$420.30
|
| Rate for Payer: GEHA Commercial |
$373.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$420.30
|
| Rate for Payer: Humana ChoiceCare |
$121.42
|
| Rate for Payer: Multiplan All |
$424.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$280.20
|
| Rate for Payer: OMNI Networks Commercial |
$326.90
|
| Rate for Payer: One Health Plan PPO/POS |
$420.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$443.65
|
| Rate for Payer: Three Rivers Provider Network All |
$350.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$410.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$116.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$434.31
|
| Rate for Payer: Zelis Auto |
$186.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$233.50
|
|
|
IMPLT SCR OST 4.7MMX20MM EVOS F-T
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
IMPLT SCR OST 4.7MMX20MM EVOS F-T
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
IMPLT SCR RATT 5X10
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$460.40 |
| Max. Negotiated Rate |
$1,093.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$920.80
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$978.35
|
| Rate for Payer: First Health Commercial |
$1,035.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,035.90
|
| Rate for Payer: GEHA Commercial |
$805.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,035.90
|
| Rate for Payer: Multiplan All |
$1,047.41
|
| Rate for Payer: OMNI Networks Commercial |
$805.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,035.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,093.45
|
| Rate for Payer: Three Rivers Provider Network All |
$863.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,070.43
|
| Rate for Payer: Zelis Auto |
$460.40
|
|
|
IMPLT SCR RATT 5X10
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$287.75 |
| Max. Negotiated Rate |
$1,093.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$690.60
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$978.35
|
| Rate for Payer: First Health Commercial |
$1,035.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,035.90
|
| Rate for Payer: GEHA Commercial |
$920.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,035.90
|
| Rate for Payer: Humana ChoiceCare |
$299.26
|
| Rate for Payer: Multiplan All |
$1,047.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$690.60
|
| Rate for Payer: OMNI Networks Commercial |
$805.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,035.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,093.45
|
| Rate for Payer: Three Rivers Provider Network All |
$863.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,012.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$287.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,070.43
|
| Rate for Payer: Zelis Auto |
$460.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$575.50
|
|
|
IMPLT SCR SN PERI 2.7X14
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$47.75 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$152.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Humana ChoiceCare |
$49.66
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.60
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$168.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$47.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$95.50
|
|
|
IMPLT SCR SN PERI 2.7X14
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001248
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.40 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$152.80
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$133.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
|
|
IMPLT SCR SN PERI 3.5X10
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$203.20
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$177.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
|
|
IMPLT SCR SN PERI 3.5X10
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$203.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Humana ChoiceCare |
$66.04
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$152.40
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$127.00
|
|
|
IMPLT SCR SN PERI 3.5X12
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002863
|
|
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 SN PERI 3.5X12
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002863
|
|
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 SN PERI 3.5X18
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$203.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Humana ChoiceCare |
$66.04
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$152.40
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$223.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$127.00
|
|
|
IMPLT SCR SN PERI 3.5X18
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$203.20
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$215.90
|
| Rate for Payer: First Health Commercial |
$228.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$228.60
|
| Rate for Payer: GEHA Commercial |
$177.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$228.60
|
| Rate for Payer: Multiplan All |
$231.14
|
| Rate for Payer: OMNI Networks Commercial |
$177.80
|
| Rate for Payer: One Health Plan PPO/POS |
$228.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$241.30
|
| Rate for Payer: Three Rivers Provider Network All |
$190.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$236.22
|
| Rate for Payer: Zelis Auto |
$101.60
|
|
|
IMPLT SCR SN PERILOC 7X16
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$47.75 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cigna Commercial |
$162.35
|
| Rate for Payer: First Health Commercial |
$171.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.90
|
| Rate for Payer: GEHA Commercial |
$152.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.90
|
| Rate for Payer: Humana ChoiceCare |
$49.66
|
| Rate for Payer: Multiplan All |
$173.81
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.60
|
| Rate for Payer: OMNI Networks Commercial |
$133.70
|
| Rate for Payer: One Health Plan PPO/POS |
$171.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$181.45
|
| Rate for Payer: Three Rivers Provider Network All |
$143.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$168.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$47.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$177.63
|
| Rate for Payer: Zelis Auto |
$76.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$95.50
|
|
