|
IMPLT STENT 4.7 X 24CM
|
Facility
|
IP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004291
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,031.94
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$902.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
|
|
IMPLT STENT 4.7 X 24CM
|
Facility
|
IP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004288
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,031.94
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$902.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
|
|
IMPLT STENT 4.7 X 26CM
|
Facility
|
OP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$322.48 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$1,031.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Humana ChoiceCare |
$335.38
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$773.95
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,135.13
|
| Rate for Payer: United Healthcare Managed Medicaid |
$322.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$644.96
|
|
|
IMPLT STENT 4.7 X 26CM
|
Facility
|
IP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,031.94
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$902.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
|
|
IMPLT STENT 4.7 X 28CM
|
Facility
|
IP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004292
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,031.94
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$902.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
|
|
IMPLT STENT 4.7 X 28CM
|
Facility
|
OP
|
$1,289.92
|
|
|
Service Code
|
CPT C1758
|
| Hospital Charge Code |
7004292
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$322.48 |
| Max. Negotiated Rate |
$1,225.42 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cash Price |
$773.95
|
| Rate for Payer: Cigna Commercial |
$1,096.43
|
| Rate for Payer: First Health Commercial |
$1,160.93
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,160.93
|
| Rate for Payer: GEHA Commercial |
$1,031.94
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,160.93
|
| Rate for Payer: Humana ChoiceCare |
$335.38
|
| Rate for Payer: Multiplan All |
$1,173.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$773.95
|
| Rate for Payer: OMNI Networks Commercial |
$902.94
|
| Rate for Payer: One Health Plan PPO/POS |
$1,160.93
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,225.42
|
| Rate for Payer: Three Rivers Provider Network All |
$967.44
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,135.13
|
| Rate for Payer: United Healthcare Managed Medicaid |
$322.48
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,199.63
|
| Rate for Payer: Zelis Auto |
$515.97
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$644.96
|
|
|
IMPLT STENT 6 FR 20
|
Facility
|
IP
|
$911.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002431
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$364.40 |
| Max. Negotiated Rate |
$865.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$728.80
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cigna Commercial |
$774.35
|
| Rate for Payer: First Health Commercial |
$819.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$819.90
|
| Rate for Payer: GEHA Commercial |
$637.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$819.90
|
| Rate for Payer: Multiplan All |
$829.01
|
| Rate for Payer: OMNI Networks Commercial |
$637.70
|
| Rate for Payer: One Health Plan PPO/POS |
$819.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$865.45
|
| Rate for Payer: Three Rivers Provider Network All |
$683.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$847.23
|
| Rate for Payer: Zelis Auto |
$364.40
|
|
|
IMPLT STENT 6 FR 20
|
Facility
|
OP
|
$911.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002431
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$227.75 |
| Max. Negotiated Rate |
$865.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$546.60
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cigna Commercial |
$774.35
|
| Rate for Payer: First Health Commercial |
$819.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$819.90
|
| Rate for Payer: GEHA Commercial |
$728.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$819.90
|
| Rate for Payer: Humana ChoiceCare |
$236.86
|
| Rate for Payer: Multiplan All |
$829.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$546.60
|
| Rate for Payer: OMNI Networks Commercial |
$637.70
|
| Rate for Payer: One Health Plan PPO/POS |
$819.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$865.45
|
| Rate for Payer: Three Rivers Provider Network All |
$683.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$801.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$227.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$847.23
|
| Rate for Payer: Zelis Auto |
$364.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$455.50
|
|
|
IMPLT STENT 6 FR CONTOUR STENT
|
Facility
|
OP
|
$938.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002432
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$891.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$562.80
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cigna Commercial |
$797.30
|
| Rate for Payer: First Health Commercial |
$844.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$844.20
|
| Rate for Payer: GEHA Commercial |
$750.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$844.20
|
| Rate for Payer: Humana ChoiceCare |
$243.88
|
| Rate for Payer: Multiplan All |
$853.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$562.80
|
| Rate for Payer: OMNI Networks Commercial |
$656.60
|
| Rate for Payer: One Health Plan PPO/POS |
$844.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$891.10
|
| Rate for Payer: Three Rivers Provider Network All |
$703.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$825.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$234.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$872.34
|
| Rate for Payer: Zelis Auto |
$375.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$469.00
|
|
|
IMPLT STENT 6 FR CONTOUR STENT
|
Facility
|
IP
|
$938.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002432
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$375.20 |
| Max. Negotiated Rate |
$891.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$750.40
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cigna Commercial |
$797.30
|
| Rate for Payer: First Health Commercial |
$844.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$844.20
|
| Rate for Payer: GEHA Commercial |
$656.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$844.20
|
| Rate for Payer: Multiplan All |
$853.58
|
| Rate for Payer: OMNI Networks Commercial |
$656.60
|
| Rate for Payer: One Health Plan PPO/POS |
$844.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$891.10
|
| Rate for Payer: Three Rivers Provider Network All |
$703.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$872.34
|
| Rate for Payer: Zelis Auto |
$375.20
|
|
|
IMPLT STENT CONTOUR 6FR.X24CM
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002443
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$792.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$708.90
|
| Rate for Payer: First Health Commercial |
$750.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$750.60
|
| Rate for Payer: GEHA Commercial |
$667.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$750.60
|
| Rate for Payer: Humana ChoiceCare |
$216.84
|
| Rate for Payer: Multiplan All |
$758.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$500.40
|
| Rate for Payer: OMNI Networks Commercial |
$583.80
|
| Rate for Payer: One Health Plan PPO/POS |
$750.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$792.30
|
| Rate for Payer: Three Rivers Provider Network All |
$625.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$733.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$775.62
|
| Rate for Payer: Zelis Auto |
$333.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$417.00
|
|
|
IMPLT STENT CONTOUR 6FR.X24CM
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002443
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.60 |
| Max. Negotiated Rate |
$792.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$667.20
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$708.90
|
| Rate for Payer: First Health Commercial |
$750.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$750.60
|
| Rate for Payer: GEHA Commercial |
$583.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$750.60
|
| Rate for Payer: Multiplan All |
$758.94
|
| Rate for Payer: OMNI Networks Commercial |
$583.80
|
| Rate for Payer: One Health Plan PPO/POS |
$750.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$792.30
|
| Rate for Payer: Three Rivers Provider Network All |
$625.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$775.62
|
| Rate for Payer: Zelis Auto |
$333.60
|
|
|
IMPLT STENT CONTOUR INJECT 6FR.X26CM
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$792.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$708.90
|
| Rate for Payer: First Health Commercial |
$750.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$750.60
|
| Rate for Payer: GEHA Commercial |
$667.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$750.60
|
| Rate for Payer: Humana ChoiceCare |
$216.84
|
| Rate for Payer: Multiplan All |
$758.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$500.40
|
| Rate for Payer: OMNI Networks Commercial |
$583.80
|
| Rate for Payer: One Health Plan PPO/POS |
$750.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$792.30
|
| Rate for Payer: Three Rivers Provider Network All |
$625.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$733.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$775.62
|
| Rate for Payer: Zelis Auto |
$333.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$417.00
|
|
|
IMPLT STENT CONTOUR INJECT 6FR.X26CM
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.60 |
| Max. Negotiated Rate |
$792.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$667.20
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cash Price |
$500.40
|
| Rate for Payer: Cigna Commercial |
$708.90
|
| Rate for Payer: First Health Commercial |
$750.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$750.60
|
| Rate for Payer: GEHA Commercial |
$583.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$750.60
|
| Rate for Payer: Multiplan All |
$758.94
|
| Rate for Payer: OMNI Networks Commercial |
$583.80
|
| Rate for Payer: One Health Plan PPO/POS |
$750.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$792.30
|
| Rate for Payer: Three Rivers Provider Network All |
$625.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$775.62
|
| Rate for Payer: Zelis Auto |
$333.60
|
|
|
IMPLT STENT COPE NEPHROURETEROSTOMY
|
Facility
|
IP
|
$669.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$267.60 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$535.20
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$468.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
|
|
IMPLT STENT COPE NEPHROURETEROSTOMY
|
Facility
|
OP
|
$669.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$167.25 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$535.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Humana ChoiceCare |
$173.94
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$401.40
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$588.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$167.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$334.50
|
|
|
IMPLT STENT COPE NEPHROURETEROSTOMY
|
Facility
|
IP
|
$669.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$267.60 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$535.20
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$468.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
|
|
IMPLT STENT COPE NEPHROURETEROSTOMY
|
Facility
|
OP
|
$669.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$167.25 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cash Price |
$401.40
|
| Rate for Payer: Cigna Commercial |
$568.65
|
| Rate for Payer: First Health Commercial |
$602.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$602.10
|
| Rate for Payer: GEHA Commercial |
$535.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$602.10
|
| Rate for Payer: Humana ChoiceCare |
$173.94
|
| Rate for Payer: Multiplan All |
$608.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$401.40
|
| Rate for Payer: OMNI Networks Commercial |
$468.30
|
| Rate for Payer: One Health Plan PPO/POS |
$602.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$635.55
|
| Rate for Payer: Three Rivers Provider Network All |
$501.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$588.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$167.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$622.17
|
| Rate for Payer: Zelis Auto |
$267.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$334.50
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
IP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$421.20 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$842.40
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$737.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
IP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$421.20 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$842.40
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$737.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009205
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$842.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Humana ChoiceCare |
$273.78
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$631.80
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$926.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$526.50
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
IP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$421.20 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$842.40
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$737.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$842.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Humana ChoiceCare |
$273.78
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$631.80
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$926.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$526.50
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
IP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$421.20 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$842.40
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$737.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
|
|
IMPLT STENT SILICONE COATED
|
Facility
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009085
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,000.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cash Price |
$631.80
|
| Rate for Payer: Cigna Commercial |
$895.05
|
| Rate for Payer: First Health Commercial |
$947.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$947.70
|
| Rate for Payer: GEHA Commercial |
$842.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$947.70
|
| Rate for Payer: Humana ChoiceCare |
$273.78
|
| Rate for Payer: Multiplan All |
$958.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$631.80
|
| Rate for Payer: OMNI Networks Commercial |
$737.10
|
| Rate for Payer: One Health Plan PPO/POS |
$947.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,000.35
|
| Rate for Payer: Three Rivers Provider Network All |
$789.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$926.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$979.29
|
| Rate for Payer: Zelis Auto |
$421.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$526.50
|
|
