|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 4
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001893
|
|
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 4
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001893
|
|
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 SIZE4 RM/LL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7000259
|
|
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 SIZE4 RM/LL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7000259
|
|
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 SIZE5 RM/LL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000260
|
|
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 SIZE5 RM/LL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000260
|
|
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 6
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006109
|
|
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 6
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006109
|
|
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 7
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003335
|
|
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 7
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003335
|
|
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 8
|
Facility
|
OP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,027.75 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$3,288.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Humana ChoiceCare |
$1,068.86
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,466.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,617.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,027.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,055.50
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SIZE 8
|
Facility
|
IP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,644.40 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,288.80
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$2,877.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
|
|
IMPLT BASEPLATE TIBIAL ONLAY SZ 7 RM/LL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003280
|
|
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 SZ 7 RM/LL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003280
|
|
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 TIBIALPRIMARY #3
|
Facility
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.60 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,879.20
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,519.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
|
|
IMPLT BASEPLATE TIBIALPRIMARY #3
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$899.75 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,879.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Humana ChoiceCare |
$935.74
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,159.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,167.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$899.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,799.50
|
|
|
IMPLT BASEPLATE TIBIAL PRIMARY SZ5
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001907
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$899.75 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,879.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Humana ChoiceCare |
$935.74
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,159.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,167.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$899.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,799.50
|
|
|
IMPLT BASEPLATE TIBIAL PRIMARY SZ5
|
Facility
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001907
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.60 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,879.20
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,519.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 2
|
Facility
|
OP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.75 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,532.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Humana ChoiceCare |
$1,147.90
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,649.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,885.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,103.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,207.50
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 2
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,012.50 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$3,240.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Humana ChoiceCare |
$1,053.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,430.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,564.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,012.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,025.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 2
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,240.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$2,835.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 2
|
Facility
|
IP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,532.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,090.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE #4
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,240.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$2,835.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE #4
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,012.50 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$3,240.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Humana ChoiceCare |
$1,053.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,430.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,564.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,012.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,025.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 4
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001895
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$899.75 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,879.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Humana ChoiceCare |
$935.74
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,159.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,167.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$899.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,799.50
|
|
