|
IMPLT BASEPLATE TIBIAL SIZE 4
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000261
|
|
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
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001895
|
|
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 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
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 5
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001896
|
|
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 5
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001896
|
|
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 SIZE5
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001899
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.00 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,884.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,273.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE5
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001899
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,884.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Humana ChoiceCare |
$1,587.30
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,663.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,372.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,526.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,052.50
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 5 LM/RL
|
Facility
|
IP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001897
|
|
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 SIZE 5 LM/RL
|
Facility
|
OP
|
$3,730.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001897
|
|
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 SIZE 6
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001898
|
|
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 6
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,101.50 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,524.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Humana ChoiceCare |
$1,145.56
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,643.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,877.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,101.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,203.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 6
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,762.40 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,524.80
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,084.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 6
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001898
|
|
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 7
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001908
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,101.50 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,524.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Humana ChoiceCare |
$1,145.56
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,643.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,877.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,101.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,203.00
|
|
|
IMPLT BASEPLATE TIBIAL SIZE 7
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001908
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,762.40 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,524.80
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,084.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
|
|
IMPLT BASEPLATE TIBIAL SZ3
|
Facility
|
OP
|
$5,813.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7000211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.25 |
| Max. Negotiated Rate |
$5,522.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,487.80
|
| Rate for Payer: Cash Price |
$3,487.80
|
| Rate for Payer: Cash Price |
$3,487.80
|
| Rate for Payer: Cigna Commercial |
$4,941.05
|
| Rate for Payer: First Health Commercial |
$5,231.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,231.70
|
| Rate for Payer: GEHA Commercial |
$4,650.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,231.70
|
| Rate for Payer: Humana ChoiceCare |
$1,511.38
|
| Rate for Payer: Multiplan All |
$5,289.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,487.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,069.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,231.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,522.35
|
| Rate for Payer: Three Rivers Provider Network All |
$4,359.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,115.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,453.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,406.09
|
| Rate for Payer: Zelis Auto |
$2,325.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,906.50
|
|
|
IMPLT BASEPLATE TIBIAL SZ3
|
Facility
|
IP
|
$5,813.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7000211
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,325.20 |
| Max. Negotiated Rate |
$5,522.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,650.40
|
| Rate for Payer: Cash Price |
$3,487.80
|
| Rate for Payer: Cash Price |
$3,487.80
|
| Rate for Payer: Cigna Commercial |
$4,941.05
|
| Rate for Payer: First Health Commercial |
$5,231.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,231.70
|
| Rate for Payer: GEHA Commercial |
$4,069.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,231.70
|
| Rate for Payer: Multiplan All |
$5,289.83
|
| Rate for Payer: OMNI Networks Commercial |
$4,069.10
|
| Rate for Payer: One Health Plan PPO/POS |
$5,231.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,522.35
|
| Rate for Payer: Three Rivers Provider Network All |
$4,359.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,406.09
|
| Rate for Payer: Zelis Auto |
$2,325.20
|
|
|
IMPLT BASEPLATE TIBIAL SZ3
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001909
|
|
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 SZ3
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001909
|
|
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 SZ5
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000262
|
|
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 SZ5
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000262
|
|
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 SZ6
|
Facility
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001910
|
|
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 SZ6
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001910
|
|
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 UNIVERSAL SIZE 2
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,762.40 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,524.80
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,084.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
|
|
IMPLT BASEPLATE TIBIAL UNIVERSAL SIZE 2
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,101.50 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Cigna Commercial |
$3,745.10
|
| Rate for Payer: First Health Commercial |
$3,965.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,965.40
|
| Rate for Payer: GEHA Commercial |
$3,524.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,965.40
|
| Rate for Payer: Humana ChoiceCare |
$1,145.56
|
| Rate for Payer: Multiplan All |
$4,009.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,643.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,084.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,965.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,185.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,304.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,877.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,101.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,097.58
|
| Rate for Payer: Zelis Auto |
$1,762.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,203.00
|
|
