|
IMPT JUGGERKNOT SINGLE SIZE 1
|
Facility
|
IP
|
$1,320.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$528.00 |
| Max. Negotiated Rate |
$1,254.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,056.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$1,122.00
|
| Rate for Payer: First Health Commercial |
$1,188.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,188.00
|
| Rate for Payer: GEHA Commercial |
$924.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,188.00
|
| Rate for Payer: Multiplan All |
$1,201.20
|
| Rate for Payer: OMNI Networks Commercial |
$924.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,188.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,254.00
|
| Rate for Payer: Three Rivers Provider Network All |
$990.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,227.60
|
| Rate for Payer: Zelis Auto |
$528.00
|
|
|
IMPT JUGGERKNOT SINGLE SIZE 1
|
Facility
|
OP
|
$1,320.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,254.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna Commercial |
$1,122.00
|
| Rate for Payer: First Health Commercial |
$1,188.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,188.00
|
| Rate for Payer: GEHA Commercial |
$1,056.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,188.00
|
| Rate for Payer: Humana ChoiceCare |
$343.20
|
| Rate for Payer: Multiplan All |
$1,201.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$792.00
|
| Rate for Payer: OMNI Networks Commercial |
$924.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,188.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,254.00
|
| Rate for Payer: Three Rivers Provider Network All |
$990.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,161.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$330.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,227.60
|
| Rate for Payer: Zelis Auto |
$528.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$660.00
|
|
|
IMPT KIRSCHNER WIRE .062"X6"
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$79.20
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$69.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
|
|
IMPT KIRSCHNER WIRE .062"X6"
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$84.15
|
| Rate for Payer: First Health Commercial |
$89.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$89.10
|
| Rate for Payer: GEHA Commercial |
$79.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$89.10
|
| Rate for Payer: Humana ChoiceCare |
$25.74
|
| Rate for Payer: Multiplan All |
$90.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$59.40
|
| Rate for Payer: OMNI Networks Commercial |
$69.30
|
| Rate for Payer: One Health Plan PPO/POS |
$89.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$94.05
|
| Rate for Payer: Three Rivers Provider Network All |
$74.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$87.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$24.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$92.07
|
| Rate for Payer: Zelis Auto |
$39.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$49.50
|
|
|
IMPT KIT PIN ORTHOSORB 2.0MM
|
Facility
|
OP
|
$889.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$222.25 |
| Max. Negotiated Rate |
$844.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cigna Commercial |
$755.65
|
| Rate for Payer: First Health Commercial |
$800.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$800.10
|
| Rate for Payer: GEHA Commercial |
$711.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$800.10
|
| Rate for Payer: Humana ChoiceCare |
$231.14
|
| Rate for Payer: Multiplan All |
$808.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$533.40
|
| Rate for Payer: OMNI Networks Commercial |
$622.30
|
| Rate for Payer: One Health Plan PPO/POS |
$800.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$844.55
|
| Rate for Payer: Three Rivers Provider Network All |
$666.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$782.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$222.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$826.77
|
| Rate for Payer: Zelis Auto |
$355.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$444.50
|
|
|
IMPT KIT PIN ORTHOSORB 2.0MM
|
Facility
|
IP
|
$889.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$355.60 |
| Max. Negotiated Rate |
$844.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$711.20
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cigna Commercial |
$755.65
|
| Rate for Payer: First Health Commercial |
$800.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$800.10
|
| Rate for Payer: GEHA Commercial |
$622.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$800.10
|
| Rate for Payer: Multiplan All |
$808.99
|
| Rate for Payer: OMNI Networks Commercial |
$622.30
|
| Rate for Payer: One Health Plan PPO/POS |
$800.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$844.55
|
| Rate for Payer: Three Rivers Provider Network All |
$666.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$826.77
|
| Rate for Payer: Zelis Auto |
$355.60
|
|
|
IMPT K-WIRE 1.1 DSDS-1011 WRIGHT
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$188.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$164.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
|
|
IMPT K-WIRE 1.1 DSDS-1011 WRIGHT
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$58.75 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$199.75
|
| Rate for Payer: First Health Commercial |
$211.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$211.50
|
| Rate for Payer: GEHA Commercial |
$188.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$211.50
|
| Rate for Payer: Humana ChoiceCare |
$61.10
|
| Rate for Payer: Multiplan All |
$213.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$141.00
|
| Rate for Payer: OMNI Networks Commercial |
$164.50
|
| Rate for Payer: One Health Plan PPO/POS |
$211.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$223.25
|
| Rate for Payer: Three Rivers Provider Network All |
$176.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$206.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$58.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$218.55
|
| Rate for Payer: Zelis Auto |
$94.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$117.50
|
|
|
IMPT K-WIRE 1.2 WRIGHT
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$45.75 |
| Max. Negotiated Rate |
$173.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$109.80
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$155.55
|
| Rate for Payer: First Health Commercial |
$164.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$164.70
|
| Rate for Payer: GEHA Commercial |
$146.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$164.70
|
| Rate for Payer: Humana ChoiceCare |
$47.58
|
| Rate for Payer: Multiplan All |
$166.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$109.80
|
| Rate for Payer: OMNI Networks Commercial |
$128.10
|
| Rate for Payer: One Health Plan PPO/POS |
$164.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$173.85
|
| Rate for Payer: Three Rivers Provider Network All |
$137.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$161.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$45.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$170.19
|
| Rate for Payer: Zelis Auto |
$73.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$91.50
|
|
|
IMPT K-WIRE 1.2 WRIGHT
|
Facility
|
IP
|
$183.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$173.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$146.40
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Cigna Commercial |
$155.55
|
| Rate for Payer: First Health Commercial |
$164.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$164.70
|
| Rate for Payer: GEHA Commercial |
$128.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$164.70
|
| Rate for Payer: Multiplan All |
$166.53
|
| Rate for Payer: OMNI Networks Commercial |
$128.10
|
| Rate for Payer: One Health Plan PPO/POS |
$164.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$173.85
|
| Rate for Payer: Three Rivers Provider Network All |
$137.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$170.19
|
| Rate for Payer: Zelis Auto |
$73.20
|
|
|
IMPT K-WIRE2.0MM
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$309.40
|
| Rate for Payer: First Health Commercial |
$327.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$327.60
|
| Rate for Payer: GEHA Commercial |
$291.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$327.60
|
| Rate for Payer: Humana ChoiceCare |
$94.64
|
| Rate for Payer: Multiplan All |
$331.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$218.40
|
| Rate for Payer: OMNI Networks Commercial |
$254.80
|
| Rate for Payer: One Health Plan PPO/POS |
$327.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$345.80
|
| Rate for Payer: Three Rivers Provider Network All |
$273.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$320.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$91.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$338.52
|
| Rate for Payer: Zelis Auto |
$145.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$182.00
|
|
|
IMPT K-WIRE2.0MM
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$291.20
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$309.40
|
| Rate for Payer: First Health Commercial |
$327.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$327.60
|
| Rate for Payer: GEHA Commercial |
$254.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$327.60
|
| Rate for Payer: Multiplan All |
$331.24
|
| Rate for Payer: OMNI Networks Commercial |
$254.80
|
| Rate for Payer: One Health Plan PPO/POS |
$327.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$345.80
|
| Rate for Payer: Three Rivers Provider Network All |
$273.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$338.52
|
| Rate for Payer: Zelis Auto |
$145.60
|
|
|
IMPT K-WIRE SN 2X228
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$162.40
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$142.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
|
|
IMPT K-WIRE SN 2X228
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$172.55
|
| Rate for Payer: First Health Commercial |
$182.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$182.70
|
| Rate for Payer: GEHA Commercial |
$162.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$182.70
|
| Rate for Payer: Humana ChoiceCare |
$52.78
|
| Rate for Payer: Multiplan All |
$184.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$121.80
|
| Rate for Payer: OMNI Networks Commercial |
$142.10
|
| Rate for Payer: One Health Plan PPO/POS |
$182.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$192.85
|
| Rate for Payer: Three Rivers Provider Network All |
$152.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$178.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$50.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$188.79
|
| Rate for Payer: Zelis Auto |
$81.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$101.50
|
|
|
IMPT K-WIRE VIL 0.9
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$52.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Humana ChoiceCare |
$17.16
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: New Mexico Health Connections Medicare |
$39.60
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$58.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$16.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$33.00
|
|
|
IMPT K-WIRE VIL 0.9
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$62.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$52.80
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$56.10
|
| Rate for Payer: First Health Commercial |
$59.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$59.40
|
| Rate for Payer: GEHA Commercial |
$46.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$59.40
|
| Rate for Payer: Multiplan All |
$60.06
|
| Rate for Payer: OMNI Networks Commercial |
$46.20
|
| Rate for Payer: One Health Plan PPO/POS |
$59.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$62.70
|
| Rate for Payer: Three Rivers Provider Network All |
$49.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$61.38
|
| Rate for Payer: Zelis Auto |
$26.40
|
|
|
IMPT PLATE 4 HOLE 31MM
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.00 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$276.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: First Health Commercial |
$310.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$310.50
|
| Rate for Payer: GEHA Commercial |
$241.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$310.50
|
| Rate for Payer: Multiplan All |
$313.95
|
| Rate for Payer: OMNI Networks Commercial |
$241.50
|
| Rate for Payer: One Health Plan PPO/POS |
$310.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$327.75
|
| Rate for Payer: Three Rivers Provider Network All |
$258.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$320.85
|
| Rate for Payer: Zelis Auto |
$138.00
|
|
|
IMPT PLATE 4 HOLE 31MM
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: First Health Commercial |
$310.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$310.50
|
| Rate for Payer: GEHA Commercial |
$276.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$310.50
|
| Rate for Payer: Humana ChoiceCare |
$89.70
|
| Rate for Payer: Multiplan All |
$313.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$207.00
|
| Rate for Payer: OMNI Networks Commercial |
$241.50
|
| Rate for Payer: One Health Plan PPO/POS |
$310.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$327.75
|
| Rate for Payer: Three Rivers Provider Network All |
$258.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$303.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$86.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$320.85
|
| Rate for Payer: Zelis Auto |
$138.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$172.50
|
|
|
IMPT SCREW 3.0 X16
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
700349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$292.00 |
| Max. Negotiated Rate |
$693.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$584.00
|
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cigna Commercial |
$620.50
|
| Rate for Payer: First Health Commercial |
$657.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$657.00
|
| Rate for Payer: GEHA Commercial |
$511.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$657.00
|
| Rate for Payer: Multiplan All |
$664.30
|
| Rate for Payer: OMNI Networks Commercial |
$511.00
|
| Rate for Payer: One Health Plan PPO/POS |
$657.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$693.50
|
| Rate for Payer: Three Rivers Provider Network All |
$547.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$678.90
|
| Rate for Payer: Zelis Auto |
$292.00
|
|
|
IMPT SCREW 3.0 X16
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
700349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.50 |
| Max. Negotiated Rate |
$693.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$438.00
|
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cash Price |
$438.00
|
| Rate for Payer: Cigna Commercial |
$620.50
|
| Rate for Payer: First Health Commercial |
$657.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$657.00
|
| Rate for Payer: GEHA Commercial |
$584.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$657.00
|
| Rate for Payer: Humana ChoiceCare |
$189.80
|
| Rate for Payer: Multiplan All |
$664.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$438.00
|
| Rate for Payer: OMNI Networks Commercial |
$511.00
|
| Rate for Payer: One Health Plan PPO/POS |
$657.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$693.50
|
| Rate for Payer: Three Rivers Provider Network All |
$547.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$642.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$182.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$678.90
|
| Rate for Payer: Zelis Auto |
$292.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$365.00
|
|
|
IMPT SCREW CORTICAL 20MM 482702001
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.00
|
| Rate for Payer: GEHA Commercial |
$152.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.00
|
| Rate for Payer: Humana ChoiceCare |
$49.40
|
| Rate for Payer: Multiplan All |
$172.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$114.00
|
| Rate for Payer: OMNI Networks Commercial |
$133.00
|
| Rate for Payer: One Health Plan PPO/POS |
$171.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.50
|
| Rate for Payer: Three Rivers Provider Network All |
$142.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$167.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$47.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.70
|
| Rate for Payer: Zelis Auto |
$76.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$95.00
|
|
|
IMPT SCREW CORTICAL 20MM 482702001
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$152.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$171.00
|
| Rate for Payer: GEHA Commercial |
$133.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$171.00
|
| Rate for Payer: Multiplan All |
$172.90
|
| Rate for Payer: OMNI Networks Commercial |
$133.00
|
| Rate for Payer: One Health Plan PPO/POS |
$171.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$180.50
|
| Rate for Payer: Three Rivers Provider Network All |
$142.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$176.70
|
| Rate for Payer: Zelis Auto |
$76.00
|
|
|
INADM ANY ROUTE ADDL VAC/
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
8590461
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$14.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
INADM ANY ROUTE ADDL VAC/
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 90461
|
| Hospital Charge Code |
8590461
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$38.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$38.51
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$30.50
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$17.85
|
| Rate for Payer: First Health Commercial |
$18.90
|
| Rate for Payer: First Health Workers Compensation |
$8.11
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$18.90
|
| Rate for Payer: GEHA Commercial |
$16.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$18.90
|
| Rate for Payer: Humana ChoiceCare |
$5.46
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$31.12
|
| Rate for Payer: Multiplan All |
$19.11
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12.60
|
| Rate for Payer: OMNI Networks Commercial |
$14.70
|
| Rate for Payer: One Health Plan PPO/POS |
$18.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$35.94
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$31.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$19.95
|
| Rate for Payer: Three Rivers Provider Network All |
$15.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$31.12
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19.53
|
| Rate for Payer: Zelis Auto |
$8.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10.50
|
| Rate for Payer: Zelis Worker's Compensation |
$5.73
|
|
|
INCENTIVE SPIROMETER
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
4000709
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$85.00
|
| Rate for Payer: First Health Commercial |
$90.00
|
| Rate for Payer: First Health Workers Compensation |
$38.61
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$90.00
|
| Rate for Payer: GEHA Commercial |
$70.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$90.00
|
| Rate for Payer: Multiplan All |
$91.00
|
| Rate for Payer: OMNI Networks Commercial |
$70.00
|
| Rate for Payer: One Health Plan PPO/POS |
$90.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$95.00
|
| Rate for Payer: Three Rivers Provider Network All |
$75.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$93.00
|
| Rate for Payer: Zelis Auto |
$40.00
|
| Rate for Payer: Zelis Worker's Compensation |
$27.30
|
|
