|
IMPLT TRIA SOFT 6 X 20
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIA SOFT 6 X 22
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIA SOFT 6 X 22
|
Facility
|
IP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$817.70
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$715.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
|
|
IMPLT TRIA SOFT 6 X 24
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIA SOFT 6 X 24
|
Facility
|
IP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$817.70
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$715.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
|
|
IMPLT TRIA SOFT 6 X 26
|
Facility
|
IP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005209
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$817.70
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$715.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
|
|
IMPLT TRIA SOFT 6 X 26
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005209
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIA SOFT 6 X 28
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIA SOFT 6 X 28
|
Facility
|
IP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$817.70
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$715.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
|
|
IMPLT TRIA SOFT 7 X 20
|
Facility
|
IP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$817.70
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$715.48
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
|
|
IMPLT TRIA SOFT 7 X 20
|
Facility
|
OP
|
$1,022.12
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.53 |
| Max. Negotiated Rate |
$971.01 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cash Price |
$613.27
|
| Rate for Payer: Cigna Commercial |
$868.80
|
| Rate for Payer: First Health Commercial |
$919.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$919.91
|
| Rate for Payer: GEHA Commercial |
$817.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$919.91
|
| Rate for Payer: Humana ChoiceCare |
$265.75
|
| Rate for Payer: Multiplan All |
$930.13
|
| Rate for Payer: New Mexico Health Connections Medicare |
$613.27
|
| Rate for Payer: OMNI Networks Commercial |
$715.48
|
| Rate for Payer: One Health Plan PPO/POS |
$919.91
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$971.01
|
| Rate for Payer: Three Rivers Provider Network All |
$766.59
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$899.47
|
| Rate for Payer: United Healthcare Managed Medicaid |
$255.53
|
| Rate for Payer: United Payors & United Providers UP&UP |
$950.57
|
| Rate for Payer: Zelis Auto |
$408.85
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$511.06
|
|
|
IMPLT TRIATHLON SZ 9
|
Facility
|
IP
|
$4,541.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.40 |
| Max. Negotiated Rate |
$4,313.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,632.80
|
| Rate for Payer: Cash Price |
$2,724.60
|
| Rate for Payer: Cash Price |
$2,724.60
|
| Rate for Payer: Cigna Commercial |
$3,859.85
|
| Rate for Payer: First Health Commercial |
$4,086.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,086.90
|
| Rate for Payer: GEHA Commercial |
$3,178.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,086.90
|
| Rate for Payer: Multiplan All |
$4,132.31
|
| Rate for Payer: OMNI Networks Commercial |
$3,178.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,086.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,313.95
|
| Rate for Payer: Three Rivers Provider Network All |
$3,405.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,223.13
|
| Rate for Payer: Zelis Auto |
$1,816.40
|
|
|
IMPLT TRIATHLON SZ 9
|
Facility
|
OP
|
$4,541.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.25 |
| Max. Negotiated Rate |
$4,313.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,724.60
|
| Rate for Payer: Cash Price |
$2,724.60
|
| Rate for Payer: Cash Price |
$2,724.60
|
| Rate for Payer: Cigna Commercial |
$3,859.85
|
| Rate for Payer: First Health Commercial |
$4,086.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,086.90
|
| Rate for Payer: GEHA Commercial |
$3,632.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,086.90
|
| Rate for Payer: Humana ChoiceCare |
$1,180.66
|
| Rate for Payer: Multiplan All |
$4,132.31
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,724.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,178.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,086.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,313.95
|
| Rate for Payer: Three Rivers Provider Network All |
$3,405.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,996.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,135.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,223.13
|
| Rate for Payer: Zelis Auto |
$1,816.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,270.50
|
|
|
IMPLT TRI-LAYER MATRIX 5X7CM
|
Facility
|
OP
|
$1,495.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002519
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$1,420.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$897.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$16.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$13.06
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,270.75
|
| Rate for Payer: First Health Commercial |
$1,345.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,345.50
|
| Rate for Payer: GEHA Commercial |
$13.07
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,345.50
|
| Rate for Payer: Humana ChoiceCare |
$388.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$13.33
|
| Rate for Payer: Multiplan All |
$1,360.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$897.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,046.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,345.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$15.39
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$13.33
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,420.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,121.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,315.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.33
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,390.35
|
| Rate for Payer: Zelis Auto |
$598.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$747.50
|
|
|
IMPLT TRI-LAYER MATRIX 5X7CM
|
Facility
|
IP
|
$1,495.00
|
|
|
Service Code
|
CPT Q4102
|
| Hospital Charge Code |
7002519
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$598.00 |
| Max. Negotiated Rate |
$1,420.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,196.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,270.75
|
| Rate for Payer: First Health Commercial |
$1,345.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,345.50
|
| Rate for Payer: GEHA Commercial |
$1,046.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,345.50
|
| Rate for Payer: Multiplan All |
$1,360.45
|
| Rate for Payer: OMNI Networks Commercial |
$1,046.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,345.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,420.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,121.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,390.35
|
| Rate for Payer: Zelis Auto |
$598.00
|
|
|
IMPLT TRIM IT ABSORB PINS
|
Facility
|
IP
|
$1,675.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$670.00 |
| Max. Negotiated Rate |
$1,591.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,340.00
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$1,423.75
|
| Rate for Payer: First Health Commercial |
$1,507.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,507.50
|
| Rate for Payer: GEHA Commercial |
$1,172.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,507.50
|
| Rate for Payer: Multiplan All |
$1,524.25
|
| Rate for Payer: OMNI Networks Commercial |
$1,172.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,507.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,591.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,256.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,557.75
|
| Rate for Payer: Zelis Auto |
$670.00
|
|
|
IMPLT TRIM IT ABSORB PINS
|
Facility
|
OP
|
$1,675.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7008011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.75 |
| Max. Negotiated Rate |
$1,591.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,005.00
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$1,423.75
|
| Rate for Payer: First Health Commercial |
$1,507.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,507.50
|
| Rate for Payer: GEHA Commercial |
$1,340.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,507.50
|
| Rate for Payer: Humana ChoiceCare |
$435.50
|
| Rate for Payer: Multiplan All |
$1,524.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,005.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,172.50
|
| Rate for Payer: One Health Plan PPO/POS |
$1,507.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,591.25
|
| Rate for Payer: Three Rivers Provider Network All |
$1,256.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,474.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$418.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,557.75
|
| Rate for Payer: Zelis Auto |
$670.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$837.50
|
|
|
IMPLT TRIPLE LOADED FIBERTAK
|
Facility
|
IP
|
$2,555.76
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,022.30 |
| Max. Negotiated Rate |
$2,427.97 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,044.61
|
| Rate for Payer: Cash Price |
$1,533.46
|
| Rate for Payer: Cash Price |
$1,533.46
|
| Rate for Payer: Cigna Commercial |
$2,172.40
|
| Rate for Payer: First Health Commercial |
$2,300.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,300.18
|
| Rate for Payer: GEHA Commercial |
$1,789.03
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,300.18
|
| Rate for Payer: Multiplan All |
$2,325.74
|
| Rate for Payer: OMNI Networks Commercial |
$1,789.03
|
| Rate for Payer: One Health Plan PPO/POS |
$2,300.18
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,427.97
|
| Rate for Payer: Three Rivers Provider Network All |
$1,916.82
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,376.86
|
| Rate for Payer: Zelis Auto |
$1,022.30
|
|
|
IMPLT TRIPLE LOADED FIBERTAK
|
Facility
|
OP
|
$2,555.76
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.94 |
| Max. Negotiated Rate |
$2,427.97 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,533.46
|
| Rate for Payer: Cash Price |
$1,533.46
|
| Rate for Payer: Cash Price |
$1,533.46
|
| Rate for Payer: Cigna Commercial |
$2,172.40
|
| Rate for Payer: First Health Commercial |
$2,300.18
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,300.18
|
| Rate for Payer: GEHA Commercial |
$2,044.61
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,300.18
|
| Rate for Payer: Humana ChoiceCare |
$664.50
|
| Rate for Payer: Multiplan All |
$2,325.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,533.46
|
| Rate for Payer: OMNI Networks Commercial |
$1,789.03
|
| Rate for Payer: One Health Plan PPO/POS |
$2,300.18
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,427.97
|
| Rate for Payer: Three Rivers Provider Network All |
$1,916.82
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,249.07
|
| Rate for Payer: United Healthcare Managed Medicaid |
$638.94
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,376.86
|
| Rate for Payer: Zelis Auto |
$1,022.30
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,277.88
|
|
|
IMPLT T-ROPE K-LESS W/DRV SYN REPR TI
|
Facility
|
IP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,906.00 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,812.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,085.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
|
|
IMPLT T-ROPE K-LESS W/DRV SYN REPR TI
|
Facility
|
OP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.25 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Humana ChoiceCare |
$1,888.90
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,359.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,393.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,816.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,632.50
|
|
|
IMPLT TUBE-T RICHARD 1.14MM
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$964.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$609.00
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cigna Commercial |
$862.75
|
| Rate for Payer: First Health Commercial |
$913.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$913.50
|
| Rate for Payer: GEHA Commercial |
$812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$913.50
|
| Rate for Payer: Humana ChoiceCare |
$263.90
|
| Rate for Payer: Multiplan All |
$923.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$609.00
|
| Rate for Payer: OMNI Networks Commercial |
$710.50
|
| Rate for Payer: One Health Plan PPO/POS |
$913.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$964.25
|
| Rate for Payer: Three Rivers Provider Network All |
$761.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$893.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$253.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$943.95
|
| Rate for Payer: Zelis Auto |
$406.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$507.50
|
|
|
IMPLT TUBE-T RICHARD 1.14MM
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006541
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$406.00 |
| Max. Negotiated Rate |
$964.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$812.00
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cigna Commercial |
$862.75
|
| Rate for Payer: First Health Commercial |
$913.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$913.50
|
| Rate for Payer: GEHA Commercial |
$710.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$913.50
|
| Rate for Payer: Multiplan All |
$923.65
|
| Rate for Payer: OMNI Networks Commercial |
$710.50
|
| Rate for Payer: One Health Plan PPO/POS |
$913.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$964.25
|
| Rate for Payer: Three Rivers Provider Network All |
$761.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$943.95
|
| Rate for Payer: Zelis Auto |
$406.00
|
|
|
IMPLT TUBE TUBE RICHARDS 1.14MM
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7002492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$176.80
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$154.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
|
|
IMPLT TUBE TUBE RICHARDS 1.14MM
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7002492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$209.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$187.85
|
| Rate for Payer: First Health Commercial |
$198.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$198.90
|
| Rate for Payer: GEHA Commercial |
$176.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$198.90
|
| Rate for Payer: Humana ChoiceCare |
$57.46
|
| Rate for Payer: Multiplan All |
$201.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$132.60
|
| Rate for Payer: OMNI Networks Commercial |
$154.70
|
| Rate for Payer: One Health Plan PPO/POS |
$198.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$209.95
|
| Rate for Payer: Three Rivers Provider Network All |
$165.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$194.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$55.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$205.53
|
| Rate for Payer: Zelis Auto |
$88.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$110.50
|
|
