|
IMPLT STENT SILICONE COATED
|
Facility
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009089
|
|
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 |
7009090
|
|
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 |
7009088
|
|
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 |
7009085
|
|
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 |
7009205
|
|
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 |
7009084
|
|
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
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009086
|
|
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 |
7009083
|
|
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 |
7009090
|
|
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
|
OP
|
$1,053.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7009082
|
|
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 |
7009084
|
|
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 |
7009083
|
|
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 |
7009082
|
|
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 URET 6FR UNV FRM 22-32CM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002436
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$494.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Humana ChoiceCare |
$160.68
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$370.80
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$543.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.00
|
|
|
IMPLT STENT URET 6FR UNV FRM 22-32CM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002436
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.20 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$432.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
|
|
IMPLT STENT URET FRM 4.7FR 24CM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$494.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Humana ChoiceCare |
$160.68
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$370.80
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$543.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.00
|
|
|
IMPLT STENT URET FRM 4.7FR 24CM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.20 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$432.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
|
|
IMPLT STENT URET UNV FRM 4.7FR 26CM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.20 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$432.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
|
|
IMPLT STENT URET UNV FRM 4.7FR 26CM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002438
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$494.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Humana ChoiceCare |
$160.68
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$370.80
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$543.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.00
|
|
|
IMPLT STENT URET UNV FRM 4.7FR 28CM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002439
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$494.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Humana ChoiceCare |
$160.68
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$370.80
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$543.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.00
|
|
|
IMPLT STENT URET UNV FRM 4.7FR 28CM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002439
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.20 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$432.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
|
|
IMPLT STENT URET UNV FRM ST 22-33CM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$494.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Humana ChoiceCare |
$160.68
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$370.80
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$543.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.00
|
|
|
IMPLT STENT URET UNV FRM ST 22-33CM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7002440
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.20 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$494.40
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$525.30
|
| Rate for Payer: First Health Commercial |
$556.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$556.20
|
| Rate for Payer: GEHA Commercial |
$432.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$556.20
|
| Rate for Payer: Multiplan All |
$562.38
|
| Rate for Payer: OMNI Networks Commercial |
$432.60
|
| Rate for Payer: One Health Plan PPO/POS |
$556.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$587.10
|
| Rate for Payer: Three Rivers Provider Network All |
$463.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$574.74
|
| Rate for Payer: Zelis Auto |
$247.20
|
|
|
IMPLT STJ BIOPRO #9
|
Facility
|
OP
|
$4,568.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.00 |
| Max. Negotiated Rate |
$4,339.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cigna Commercial |
$3,882.80
|
| Rate for Payer: First Health Commercial |
$4,111.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,111.20
|
| Rate for Payer: GEHA Commercial |
$3,654.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,111.20
|
| Rate for Payer: Humana ChoiceCare |
$1,187.68
|
| Rate for Payer: Multiplan All |
$4,156.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,740.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,197.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,111.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,339.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,019.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,248.24
|
| Rate for Payer: Zelis Auto |
$1,827.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,284.00
|
|
|
IMPLT STJ BIOPRO #9
|
Facility
|
IP
|
$4,568.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,827.20 |
| Max. Negotiated Rate |
$4,339.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,654.40
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cigna Commercial |
$3,882.80
|
| Rate for Payer: First Health Commercial |
$4,111.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,111.20
|
| Rate for Payer: GEHA Commercial |
$3,197.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,111.20
|
| Rate for Payer: Multiplan All |
$4,156.88
|
| Rate for Payer: OMNI Networks Commercial |
$3,197.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,111.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,339.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,426.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,248.24
|
| Rate for Payer: Zelis Auto |
$1,827.20
|
|
