|
IMPLT ULTRATAPE BLUE
|
Facility
|
IP
|
$1,533.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005195
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.20 |
| Max. Negotiated Rate |
$1,456.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,226.40
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cigna Commercial |
$1,303.05
|
| Rate for Payer: First Health Commercial |
$1,379.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,379.70
|
| Rate for Payer: GEHA Commercial |
$1,073.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,379.70
|
| Rate for Payer: Multiplan All |
$1,395.03
|
| Rate for Payer: OMNI Networks Commercial |
$1,073.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,379.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,456.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,425.69
|
| Rate for Payer: Zelis Auto |
$613.20
|
|
|
IMPLT ULTRATAPE BLUE
|
Facility
|
OP
|
$1,533.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7005195
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$383.25 |
| Max. Negotiated Rate |
$1,456.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cigna Commercial |
$1,303.05
|
| Rate for Payer: First Health Commercial |
$1,379.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,379.70
|
| Rate for Payer: GEHA Commercial |
$1,226.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,379.70
|
| Rate for Payer: Humana ChoiceCare |
$398.58
|
| Rate for Payer: Multiplan All |
$1,395.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$919.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,073.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,379.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,456.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,349.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$383.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,425.69
|
| Rate for Payer: Zelis Auto |
$613.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$766.50
|
|
|
IMPLT ULTRBRAID WHITE #2
|
Facility
|
OP
|
$1,533.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$383.25 |
| Max. Negotiated Rate |
$1,456.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cigna Commercial |
$1,303.05
|
| Rate for Payer: First Health Commercial |
$1,379.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,379.70
|
| Rate for Payer: GEHA Commercial |
$1,226.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,379.70
|
| Rate for Payer: Humana ChoiceCare |
$398.58
|
| Rate for Payer: Multiplan All |
$1,395.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$919.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,073.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,379.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,456.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,349.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$383.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,425.69
|
| Rate for Payer: Zelis Auto |
$613.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$766.50
|
|
|
IMPLT ULTRBRAID WHITE #2
|
Facility
|
IP
|
$1,533.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.20 |
| Max. Negotiated Rate |
$1,456.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,226.40
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cash Price |
$919.80
|
| Rate for Payer: Cigna Commercial |
$1,303.05
|
| Rate for Payer: First Health Commercial |
$1,379.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,379.70
|
| Rate for Payer: GEHA Commercial |
$1,073.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,379.70
|
| Rate for Payer: Multiplan All |
$1,395.03
|
| Rate for Payer: OMNI Networks Commercial |
$1,073.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,379.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,456.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,149.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,425.69
|
| Rate for Payer: Zelis Auto |
$613.20
|
|
|
IMPLT UNIPOLAR 42MM
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.00 |
| Max. Negotiated Rate |
$973.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$820.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$871.25
|
| Rate for Payer: First Health Commercial |
$922.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$922.50
|
| Rate for Payer: GEHA Commercial |
$717.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$922.50
|
| Rate for Payer: Multiplan All |
$932.75
|
| Rate for Payer: OMNI Networks Commercial |
$717.50
|
| Rate for Payer: One Health Plan PPO/POS |
$922.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$973.75
|
| Rate for Payer: Three Rivers Provider Network All |
$768.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$953.25
|
| Rate for Payer: Zelis Auto |
$410.00
|
|
|
IMPLT UNIPOLAR 42MM
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.25 |
| Max. Negotiated Rate |
$973.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$871.25
|
| Rate for Payer: First Health Commercial |
$922.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$922.50
|
| Rate for Payer: GEHA Commercial |
$820.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$922.50
|
| Rate for Payer: Humana ChoiceCare |
$266.50
|
| Rate for Payer: Multiplan All |
$932.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$615.00
|
| Rate for Payer: OMNI Networks Commercial |
$717.50
|
| Rate for Payer: One Health Plan PPO/POS |
$922.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$973.75
|
| Rate for Payer: Three Rivers Provider Network All |
$768.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$902.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$256.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$953.25
|
| Rate for Payer: Zelis Auto |
$410.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$512.50
|
|
|
IMPLT UNIPOLAR 45MM
|
Facility
|
IP
|
$2,211.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,100.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,768.80
|
| Rate for Payer: Cash Price |
$1,326.60
|
| Rate for Payer: Cash Price |
$1,326.60
|
| Rate for Payer: Cigna Commercial |
$1,879.35
|
| Rate for Payer: First Health Commercial |
$1,989.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,989.90
|
| Rate for Payer: GEHA Commercial |
$1,547.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,989.90
|
| Rate for Payer: Multiplan All |
$2,012.01
|
| Rate for Payer: OMNI Networks Commercial |
$1,547.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,989.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,100.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,658.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,056.23
|
| Rate for Payer: Zelis Auto |
$884.40
|
|
|
IMPLT UNIPOLAR 45MM
|
Facility
|
OP
|
$2,211.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$552.75 |
| Max. Negotiated Rate |
$2,100.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,326.60
|
| Rate for Payer: Cash Price |
$1,326.60
|
| Rate for Payer: Cash Price |
$1,326.60
|
| Rate for Payer: Cigna Commercial |
$1,879.35
|
| Rate for Payer: First Health Commercial |
$1,989.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,989.90
|
| Rate for Payer: GEHA Commercial |
$1,768.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,989.90
|
| Rate for Payer: Humana ChoiceCare |
$574.86
|
| Rate for Payer: Multiplan All |
$2,012.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,326.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,547.70
|
| Rate for Payer: One Health Plan PPO/POS |
$1,989.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,100.45
|
| Rate for Payer: Three Rivers Provider Network All |
$1,658.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,945.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$552.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,056.23
|
| Rate for Payer: Zelis Auto |
$884.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,105.50
|
|
|
IMPLT UNIPOLAR 51MM
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.25 |
| Max. Negotiated Rate |
$973.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$871.25
|
| Rate for Payer: First Health Commercial |
$922.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$922.50
|
| Rate for Payer: GEHA Commercial |
$820.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$922.50
|
| Rate for Payer: Humana ChoiceCare |
$266.50
|
| Rate for Payer: Multiplan All |
$932.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$615.00
|
| Rate for Payer: OMNI Networks Commercial |
$717.50
|
| Rate for Payer: One Health Plan PPO/POS |
$922.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$973.75
|
| Rate for Payer: Three Rivers Provider Network All |
$768.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$902.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$256.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$953.25
|
| Rate for Payer: Zelis Auto |
$410.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$512.50
|
|
|
IMPLT UNIPOLAR 51MM
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.00 |
| Max. Negotiated Rate |
$973.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$820.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$871.25
|
| Rate for Payer: First Health Commercial |
$922.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$922.50
|
| Rate for Payer: GEHA Commercial |
$717.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$922.50
|
| Rate for Payer: Multiplan All |
$932.75
|
| Rate for Payer: OMNI Networks Commercial |
$717.50
|
| Rate for Payer: One Health Plan PPO/POS |
$922.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$973.75
|
| Rate for Payer: Three Rivers Provider Network All |
$768.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$953.25
|
| Rate for Payer: Zelis Auto |
$410.00
|
|
|
IMPLT UNIVERS VAULTLOCK GLENOID SM
|
Facility
|
IP
|
$5,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,190.00 |
| Max. Negotiated Rate |
$5,201.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,380.00
|
| Rate for Payer: Cash Price |
$3,285.00
|
| Rate for Payer: Cash Price |
$3,285.00
|
| Rate for Payer: Cigna Commercial |
$4,653.75
|
| Rate for Payer: First Health Commercial |
$4,927.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,927.50
|
| Rate for Payer: GEHA Commercial |
$3,832.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,927.50
|
| Rate for Payer: Multiplan All |
$4,982.25
|
| Rate for Payer: OMNI Networks Commercial |
$3,832.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,927.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,201.25
|
| Rate for Payer: Three Rivers Provider Network All |
$4,106.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,091.75
|
| Rate for Payer: Zelis Auto |
$2,190.00
|
|
|
IMPLT UNIVERS VAULTLOCK GLENOID SM
|
Facility
|
OP
|
$5,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,368.75 |
| Max. Negotiated Rate |
$5,201.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,285.00
|
| Rate for Payer: Cash Price |
$3,285.00
|
| Rate for Payer: Cash Price |
$3,285.00
|
| Rate for Payer: Cigna Commercial |
$4,653.75
|
| Rate for Payer: First Health Commercial |
$4,927.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,927.50
|
| Rate for Payer: GEHA Commercial |
$4,380.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,927.50
|
| Rate for Payer: Humana ChoiceCare |
$1,423.50
|
| Rate for Payer: Multiplan All |
$4,982.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,285.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,832.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,927.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,201.25
|
| Rate for Payer: Three Rivers Provider Network All |
$4,106.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,818.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,368.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,091.75
|
| Rate for Payer: Zelis Auto |
$2,190.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,737.50
|
|
|
IMPLT UROMAX BALLOON 12FX4CM
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$140.50 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$337.20
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cigna Commercial |
$477.70
|
| Rate for Payer: First Health Commercial |
$505.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$505.80
|
| Rate for Payer: GEHA Commercial |
$449.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$505.80
|
| Rate for Payer: Humana ChoiceCare |
$146.12
|
| Rate for Payer: Multiplan All |
$511.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$337.20
|
| Rate for Payer: OMNI Networks Commercial |
$393.40
|
| Rate for Payer: One Health Plan PPO/POS |
$505.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$533.90
|
| Rate for Payer: Three Rivers Provider Network All |
$421.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$494.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$140.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$522.66
|
| Rate for Payer: Zelis Auto |
$224.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$281.00
|
|
|
IMPLT UROMAX BALLOON 12FX4CM
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$224.80 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$449.60
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Cigna Commercial |
$477.70
|
| Rate for Payer: First Health Commercial |
$505.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$505.80
|
| Rate for Payer: GEHA Commercial |
$393.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$505.80
|
| Rate for Payer: Multiplan All |
$511.42
|
| Rate for Payer: OMNI Networks Commercial |
$393.40
|
| Rate for Payer: One Health Plan PPO/POS |
$505.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$533.90
|
| Rate for Payer: Three Rivers Provider Network All |
$421.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$522.66
|
| Rate for Payer: Zelis Auto |
$224.80
|
|
|
IMPLT UROMAX BALLOON 15FX4CM
|
Facility
|
IP
|
$1,282.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$512.80 |
| Max. Negotiated Rate |
$1,217.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,025.60
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$1,089.70
|
| Rate for Payer: First Health Commercial |
$1,153.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,153.80
|
| Rate for Payer: GEHA Commercial |
$897.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,153.80
|
| Rate for Payer: Multiplan All |
$1,166.62
|
| Rate for Payer: OMNI Networks Commercial |
$897.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,153.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,217.90
|
| Rate for Payer: Three Rivers Provider Network All |
$961.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,192.26
|
| Rate for Payer: Zelis Auto |
$512.80
|
|
|
IMPLT UROMAX BALLOON 15FX4CM
|
Facility
|
OP
|
$1,282.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7001661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.50 |
| Max. Negotiated Rate |
$1,217.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$1,089.70
|
| Rate for Payer: First Health Commercial |
$1,153.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,153.80
|
| Rate for Payer: GEHA Commercial |
$1,025.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,153.80
|
| Rate for Payer: Humana ChoiceCare |
$333.32
|
| Rate for Payer: Multiplan All |
$1,166.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$769.20
|
| Rate for Payer: OMNI Networks Commercial |
$897.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,153.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,217.90
|
| Rate for Payer: Three Rivers Provider Network All |
$961.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,128.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$320.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,192.26
|
| Rate for Payer: Zelis Auto |
$512.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$641.00
|
|
|
IMPLT UROMAX BALLOON 18FX4CM
|
Facility
|
OP
|
$1,282.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7002890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.50 |
| Max. Negotiated Rate |
$1,217.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$1,089.70
|
| Rate for Payer: First Health Commercial |
$1,153.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,153.80
|
| Rate for Payer: GEHA Commercial |
$1,025.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,153.80
|
| Rate for Payer: Humana ChoiceCare |
$333.32
|
| Rate for Payer: Multiplan All |
$1,166.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$769.20
|
| Rate for Payer: OMNI Networks Commercial |
$897.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,153.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,217.90
|
| Rate for Payer: Three Rivers Provider Network All |
$961.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,128.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$320.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,192.26
|
| Rate for Payer: Zelis Auto |
$512.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$641.00
|
|
|
IMPLT UROMAX BALLOON 18FX4CM
|
Facility
|
IP
|
$1,282.00
|
|
|
Service Code
|
CPT C1726
|
| Hospital Charge Code |
7002890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$512.80 |
| Max. Negotiated Rate |
$1,217.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,025.60
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$1,089.70
|
| Rate for Payer: First Health Commercial |
$1,153.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,153.80
|
| Rate for Payer: GEHA Commercial |
$897.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,153.80
|
| Rate for Payer: Multiplan All |
$1,166.62
|
| Rate for Payer: OMNI Networks Commercial |
$897.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,153.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,217.90
|
| Rate for Payer: Three Rivers Provider Network All |
$961.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,192.26
|
| Rate for Payer: Zelis Auto |
$512.80
|
|
|
IMPLT WASHER
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$200.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Humana ChoiceCare |
$65.00
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$150.00
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$220.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$62.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: Zelis Auto |
$100.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$125.00
|
|
|
IMPLT WASHER
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$200.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$212.50
|
| Rate for Payer: First Health Commercial |
$225.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$225.00
|
| Rate for Payer: GEHA Commercial |
$175.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$225.00
|
| Rate for Payer: Multiplan All |
$227.50
|
| Rate for Payer: OMNI Networks Commercial |
$175.00
|
| Rate for Payer: One Health Plan PPO/POS |
$225.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$237.50
|
| Rate for Payer: Three Rivers Provider Network All |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$232.50
|
| Rate for Payer: Zelis Auto |
$100.00
|
|
|
IMPLT WASHER 3.5MM
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001091
|
|
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 WASHER 3.5MM
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001091
|
|
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 WASHER 3MM MIC ASNS
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$328.80
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$438.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Humana ChoiceCare |
$142.48
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$328.80
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$482.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$137.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: Zelis Auto |
$219.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$274.00
|
|
|
IMPLT WASHER 3MM MIC ASNS
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$219.20 |
| Max. Negotiated Rate |
$520.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$438.40
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cash Price |
$328.80
|
| Rate for Payer: Cigna Commercial |
$465.80
|
| Rate for Payer: First Health Commercial |
$493.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$493.20
|
| Rate for Payer: GEHA Commercial |
$383.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$493.20
|
| Rate for Payer: Multiplan All |
$498.68
|
| Rate for Payer: OMNI Networks Commercial |
$383.60
|
| Rate for Payer: One Health Plan PPO/POS |
$493.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$520.60
|
| Rate for Payer: Three Rivers Provider Network All |
$411.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$509.64
|
| Rate for Payer: Zelis Auto |
$219.20
|
|
|
IMPLT WASHER 4.0MM
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.20 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$202.40
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$215.05
|
| Rate for Payer: First Health Commercial |
$227.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$227.70
|
| Rate for Payer: GEHA Commercial |
$177.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$227.70
|
| Rate for Payer: Multiplan All |
$230.23
|
| Rate for Payer: OMNI Networks Commercial |
$177.10
|
| Rate for Payer: One Health Plan PPO/POS |
$227.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$240.35
|
| Rate for Payer: Three Rivers Provider Network All |
$189.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$235.29
|
| Rate for Payer: Zelis Auto |
$101.20
|
|
