|
IMPLT BASEPLATE TIBIAL INSERT 4
|
Facility
|
OP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.75 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,639.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Humana ChoiceCare |
$857.74
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,979.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,903.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$824.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,649.50
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 4
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 4
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006462
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 7
|
Facility
|
OP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.75 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,639.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Humana ChoiceCare |
$857.74
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,979.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,903.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$824.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,649.50
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 7
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 8
|
Facility
|
OP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.75 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,639.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Humana ChoiceCare |
$857.74
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,979.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,903.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$824.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,649.50
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 8
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 8
|
Facility
|
OP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.75 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,639.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Humana ChoiceCare |
$857.74
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,979.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,903.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$824.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,649.50
|
|
|
IMPLT BASEPLATE TIBIAL INSERT 8
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL INSERT X3
|
Facility
|
OP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.75 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,639.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Humana ChoiceCare |
$857.74
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,979.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,903.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$824.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,649.50
|
|
|
IMPLT BASEPLATE TIBIAL INSERT X3
|
Facility
|
IP
|
$3,299.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003497
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.60 |
| Max. Negotiated Rate |
$3,134.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,639.20
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cash Price |
$1,979.40
|
| Rate for Payer: Cigna Commercial |
$2,804.15
|
| Rate for Payer: First Health Commercial |
$2,969.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,969.10
|
| Rate for Payer: GEHA Commercial |
$2,309.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,969.10
|
| Rate for Payer: Multiplan All |
$3,002.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,309.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,969.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,134.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,474.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,068.07
|
| Rate for Payer: Zelis Auto |
$1,319.60
|
|
|
IMPLT BASEPLATE TIBIAL MRH
|
Facility
|
IP
|
$9,145.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,658.00 |
| Max. Negotiated Rate |
$8,687.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,316.00
|
| Rate for Payer: Cash Price |
$5,487.00
|
| Rate for Payer: Cash Price |
$5,487.00
|
| Rate for Payer: Cigna Commercial |
$7,773.25
|
| Rate for Payer: First Health Commercial |
$8,230.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,230.50
|
| Rate for Payer: GEHA Commercial |
$6,401.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,230.50
|
| Rate for Payer: Multiplan All |
$8,321.95
|
| Rate for Payer: OMNI Networks Commercial |
$6,401.50
|
| Rate for Payer: One Health Plan PPO/POS |
$8,230.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,687.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,858.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,504.85
|
| Rate for Payer: Zelis Auto |
$3,658.00
|
|
|
IMPLT BASEPLATE TIBIAL MRH
|
Facility
|
OP
|
$9,145.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,286.25 |
| Max. Negotiated Rate |
$8,687.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,487.00
|
| Rate for Payer: Cash Price |
$5,487.00
|
| Rate for Payer: Cash Price |
$5,487.00
|
| Rate for Payer: Cigna Commercial |
$7,773.25
|
| Rate for Payer: First Health Commercial |
$8,230.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,230.50
|
| Rate for Payer: GEHA Commercial |
$7,316.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,230.50
|
| Rate for Payer: Humana ChoiceCare |
$2,377.70
|
| Rate for Payer: Multiplan All |
$8,321.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,487.00
|
| Rate for Payer: OMNI Networks Commercial |
$6,401.50
|
| Rate for Payer: One Health Plan PPO/POS |
$8,230.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,687.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,858.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,047.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,286.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,504.85
|
| Rate for Payer: Zelis Auto |
$3,658.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,572.50
|
|
|
IMPLT BASEPLATE TIBIAL NON POROUS LEFT
|
Facility
|
IP
|
$3,045.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,436.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,131.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
|
|
IMPLT BASEPLATE TIBIAL NON POROUS LEFT
|
Facility
|
OP
|
$3,045.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$761.25 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,436.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Humana ChoiceCare |
$791.70
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,827.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,679.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$761.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,522.50
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 1RM/LL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.00 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,984.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,611.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 1RM/LL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.50 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,984.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Humana ChoiceCare |
$969.80
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,238.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,282.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,865.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 2RM/LL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.00 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,984.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,611.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 2RM/LL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.50 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,984.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Humana ChoiceCare |
$969.80
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,238.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,282.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,865.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 3 SIZE MAKO
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.50 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,984.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Humana ChoiceCare |
$969.80
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,238.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,282.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,865.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY 3 SIZE MAKO
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.00 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,984.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,611.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 2
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.00 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,984.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,611.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 2
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.50 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,984.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Humana ChoiceCare |
$969.80
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,238.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,282.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,865.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 3
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.00 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,984.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,611.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 3
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$932.50 |
| Max. Negotiated Rate |
$3,543.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,170.50
|
| Rate for Payer: First Health Commercial |
$3,357.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,357.00
|
| Rate for Payer: GEHA Commercial |
$2,984.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,357.00
|
| Rate for Payer: Humana ChoiceCare |
$969.80
|
| Rate for Payer: Multiplan All |
$3,394.30
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,238.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,611.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,357.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,543.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,282.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$932.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,468.90
|
| Rate for Payer: Zelis Auto |
$1,492.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,865.00
|
|
