|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ C LM
|
Facility
|
OP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003194
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,137.75 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$10,040.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Humana ChoiceCare |
$3,263.26
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,530.60
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,044.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,137.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,275.50
|
|
|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ C LM
|
Facility
|
IP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003194
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,020.40 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,040.80
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$8,785.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
|
|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ C LM
|
Facility
|
OP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,137.75 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$10,040.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Humana ChoiceCare |
$3,263.26
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,530.60
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,044.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,137.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,275.50
|
|
|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ C LM
|
Facility
|
IP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,020.40 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,040.80
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$8,785.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
|
|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ E RM
|
Facility
|
OP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,137.75 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$10,040.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Humana ChoiceCare |
$3,263.26
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,530.60
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,044.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,137.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,275.50
|
|
|
IMPLT AUGMENT CONE ASYMM TIBIAL SZ E RM
|
Facility
|
IP
|
$12,551.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,020.40 |
| Max. Negotiated Rate |
$11,923.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,040.80
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cash Price |
$7,530.60
|
| Rate for Payer: Cigna Commercial |
$10,668.35
|
| Rate for Payer: First Health Commercial |
$11,295.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,295.90
|
| Rate for Payer: GEHA Commercial |
$8,785.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,295.90
|
| Rate for Payer: Multiplan All |
$11,421.41
|
| Rate for Payer: OMNI Networks Commercial |
$8,785.70
|
| Rate for Payer: One Health Plan PPO/POS |
$11,295.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,923.45
|
| Rate for Payer: Three Rivers Provider Network All |
$9,413.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,672.43
|
| Rate for Payer: Zelis Auto |
$5,020.40
|
|
|
IMPLT AUGMENT DISTAL 10X70MM
|
Facility
|
OP
|
$4,604.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,151.00 |
| Max. Negotiated Rate |
$4,373.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cigna Commercial |
$3,913.40
|
| Rate for Payer: First Health Commercial |
$4,143.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,143.60
|
| Rate for Payer: GEHA Commercial |
$3,683.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,143.60
|
| Rate for Payer: Humana ChoiceCare |
$1,197.04
|
| Rate for Payer: Multiplan All |
$4,189.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,762.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,222.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,143.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,373.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,453.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,051.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,151.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,281.72
|
| Rate for Payer: Zelis Auto |
$1,841.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,302.00
|
|
|
IMPLT AUGMENT DISTAL 10X70MM
|
Facility
|
IP
|
$4,604.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001792
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,841.60 |
| Max. Negotiated Rate |
$4,373.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,683.20
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cigna Commercial |
$3,913.40
|
| Rate for Payer: First Health Commercial |
$4,143.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,143.60
|
| Rate for Payer: GEHA Commercial |
$3,222.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,143.60
|
| Rate for Payer: Multiplan All |
$4,189.64
|
| Rate for Payer: OMNI Networks Commercial |
$3,222.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,143.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,373.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,453.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,281.72
|
| Rate for Payer: Zelis Auto |
$1,841.60
|
|
|
IMPLT AUGMENT DISTAL 15X70MM
|
Facility
|
OP
|
$4,604.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,151.00 |
| Max. Negotiated Rate |
$4,373.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cigna Commercial |
$3,913.40
|
| Rate for Payer: First Health Commercial |
$4,143.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,143.60
|
| Rate for Payer: GEHA Commercial |
$3,683.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,143.60
|
| Rate for Payer: Humana ChoiceCare |
$1,197.04
|
| Rate for Payer: Multiplan All |
$4,189.64
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,762.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,222.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,143.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,373.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,453.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,051.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,151.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,281.72
|
| Rate for Payer: Zelis Auto |
$1,841.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,302.00
|
|
|
IMPLT AUGMENT DISTAL 15X70MM
|
Facility
|
IP
|
$4,604.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,841.60 |
| Max. Negotiated Rate |
$4,373.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,683.20
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cash Price |
$2,762.40
|
| Rate for Payer: Cigna Commercial |
$3,913.40
|
| Rate for Payer: First Health Commercial |
$4,143.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,143.60
|
| Rate for Payer: GEHA Commercial |
$3,222.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,143.60
|
| Rate for Payer: Multiplan All |
$4,189.64
|
| Rate for Payer: OMNI Networks Commercial |
$3,222.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,143.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,373.80
|
| Rate for Payer: Three Rivers Provider Network All |
$3,453.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,281.72
|
| Rate for Payer: Zelis Auto |
$1,841.60
|
|
|
IMPLT AUGMENT DISTAL FEMORAL LEFT SZ 7
|
Facility
|
OP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003232
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,985.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Humana ChoiceCare |
$970.32
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,239.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,284.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$933.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,866.00
|
|
|
IMPLT AUGMENT DISTAL FEMORAL LEFT SZ 7
|
Facility
|
IP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003232
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.80 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,985.60
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,612.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006202
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,430.00 |
| Max. Negotiated Rate |
$3,396.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,860.00
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Cigna Commercial |
$3,038.75
|
| Rate for Payer: First Health Commercial |
$3,217.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,217.50
|
| Rate for Payer: GEHA Commercial |
$2,502.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,217.50
|
| Rate for Payer: Multiplan All |
$3,253.25
|
| Rate for Payer: OMNI Networks Commercial |
$2,502.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,217.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,396.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,681.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,324.75
|
| Rate for Payer: Zelis Auto |
$1,430.00
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006202
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$893.75 |
| Max. Negotiated Rate |
$3,396.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,145.00
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Cash Price |
$2,145.00
|
| Rate for Payer: Cigna Commercial |
$3,038.75
|
| Rate for Payer: First Health Commercial |
$3,217.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,217.50
|
| Rate for Payer: GEHA Commercial |
$2,860.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,217.50
|
| Rate for Payer: Humana ChoiceCare |
$929.50
|
| Rate for Payer: Multiplan All |
$3,253.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,145.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,502.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,217.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,396.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,681.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,146.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$893.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,324.75
|
| Rate for Payer: Zelis Auto |
$1,430.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,787.50
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
OP
|
$3,769.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$942.25 |
| Max. Negotiated Rate |
$3,580.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,261.40
|
| Rate for Payer: Cash Price |
$2,261.40
|
| Rate for Payer: Cash Price |
$2,261.40
|
| Rate for Payer: Cigna Commercial |
$3,203.65
|
| Rate for Payer: First Health Commercial |
$3,392.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,392.10
|
| Rate for Payer: GEHA Commercial |
$3,015.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,392.10
|
| Rate for Payer: Humana ChoiceCare |
$979.94
|
| Rate for Payer: Multiplan All |
$3,429.79
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,261.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,638.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,392.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,580.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,826.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,316.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$942.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,505.17
|
| Rate for Payer: Zelis Auto |
$1,507.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,884.50
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
OP
|
$3,863.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.75 |
| Max. Negotiated Rate |
$3,669.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,317.80
|
| Rate for Payer: Cash Price |
$2,317.80
|
| Rate for Payer: Cash Price |
$2,317.80
|
| Rate for Payer: Cigna Commercial |
$3,283.55
|
| Rate for Payer: First Health Commercial |
$3,476.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,476.70
|
| Rate for Payer: GEHA Commercial |
$3,090.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,476.70
|
| Rate for Payer: Humana ChoiceCare |
$1,004.38
|
| Rate for Payer: Multiplan All |
$3,515.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,317.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,704.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,476.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,669.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,897.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,399.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$965.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,592.59
|
| Rate for Payer: Zelis Auto |
$1,545.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,931.50
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
IP
|
$3,863.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,545.20 |
| Max. Negotiated Rate |
$3,669.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,090.40
|
| Rate for Payer: Cash Price |
$2,317.80
|
| Rate for Payer: Cash Price |
$2,317.80
|
| Rate for Payer: Cigna Commercial |
$3,283.55
|
| Rate for Payer: First Health Commercial |
$3,476.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,476.70
|
| Rate for Payer: GEHA Commercial |
$2,704.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,476.70
|
| Rate for Payer: Multiplan All |
$3,515.33
|
| Rate for Payer: OMNI Networks Commercial |
$2,704.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,476.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,669.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,897.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,592.59
|
| Rate for Payer: Zelis Auto |
$1,545.20
|
|
|
IMPLT AUGMENT DISTAL FEMORAL RIGHT #5
|
Facility
|
IP
|
$3,769.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,507.60 |
| Max. Negotiated Rate |
$3,580.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,015.20
|
| Rate for Payer: Cash Price |
$2,261.40
|
| Rate for Payer: Cash Price |
$2,261.40
|
| Rate for Payer: Cigna Commercial |
$3,203.65
|
| Rate for Payer: First Health Commercial |
$3,392.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,392.10
|
| Rate for Payer: GEHA Commercial |
$2,638.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,392.10
|
| Rate for Payer: Multiplan All |
$3,429.79
|
| Rate for Payer: OMNI Networks Commercial |
$2,638.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,392.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,580.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,826.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,505.17
|
| Rate for Payer: Zelis Auto |
$1,507.60
|
|
|
IMPLT AUGMENT DISTAL FEMORAL SIZE 7
|
Facility
|
OP
|
$3,618.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$904.50 |
| Max. Negotiated Rate |
$3,437.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,170.80
|
| Rate for Payer: Cash Price |
$2,170.80
|
| Rate for Payer: Cash Price |
$2,170.80
|
| Rate for Payer: Cigna Commercial |
$3,075.30
|
| Rate for Payer: First Health Commercial |
$3,256.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,256.20
|
| Rate for Payer: GEHA Commercial |
$2,894.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,256.20
|
| Rate for Payer: Humana ChoiceCare |
$940.68
|
| Rate for Payer: Multiplan All |
$3,292.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,170.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,532.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,256.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,437.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,713.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,183.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$904.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,364.74
|
| Rate for Payer: Zelis Auto |
$1,447.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,809.00
|
|
|
IMPLT AUGMENT DISTAL FEMORAL SIZE 7
|
Facility
|
IP
|
$3,618.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,447.20 |
| Max. Negotiated Rate |
$3,437.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,894.40
|
| Rate for Payer: Cash Price |
$2,170.80
|
| Rate for Payer: Cash Price |
$2,170.80
|
| Rate for Payer: Cigna Commercial |
$3,075.30
|
| Rate for Payer: First Health Commercial |
$3,256.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,256.20
|
| Rate for Payer: GEHA Commercial |
$2,532.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,256.20
|
| Rate for Payer: Multiplan All |
$3,292.38
|
| Rate for Payer: OMNI Networks Commercial |
$2,532.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,256.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,437.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,713.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,364.74
|
| Rate for Payer: Zelis Auto |
$1,447.20
|
|
|
IMPLT AUGMENT DISTAL LEFT SZ6 5MM
|
Facility
|
OP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003239
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,985.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Humana ChoiceCare |
$970.32
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,239.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,284.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$933.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,866.00
|
|
|
IMPLT AUGMENT DISTAL LEFT SZ6 5MM
|
Facility
|
IP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003239
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.80 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,985.60
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,612.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
|
|
IMPLT AUGMENT DISTAL RIGHT SZ6 5MM
|
Facility
|
IP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.80 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,985.60
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,612.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
|
|
IMPLT AUGMENT DISTAL RIGHT SZ6 5MM
|
Facility
|
OP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,985.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Humana ChoiceCare |
$970.32
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,239.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,284.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$933.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,866.00
|
|
|
IMPLT AUGMENT FEMORAL DISTAL #2 RIGHT
|
Facility
|
OP
|
$4,682.16
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002940
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.54 |
| Max. Negotiated Rate |
$4,448.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,809.30
|
| Rate for Payer: Cash Price |
$2,809.30
|
| Rate for Payer: Cash Price |
$2,809.30
|
| Rate for Payer: Cigna Commercial |
$3,979.84
|
| Rate for Payer: First Health Commercial |
$4,213.94
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,213.94
|
| Rate for Payer: GEHA Commercial |
$3,745.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,213.94
|
| Rate for Payer: Humana ChoiceCare |
$1,217.36
|
| Rate for Payer: Multiplan All |
$4,260.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,809.30
|
| Rate for Payer: OMNI Networks Commercial |
$3,277.51
|
| Rate for Payer: One Health Plan PPO/POS |
$4,213.94
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,448.05
|
| Rate for Payer: Three Rivers Provider Network All |
$3,511.62
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,120.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,170.54
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,354.41
|
| Rate for Payer: Zelis Auto |
$1,872.86
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,341.08
|
|
