|
IMPLT BASEPLATE TIBIAL UNIVERSAL SIZE 4
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001902
|
|
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 UNIVERSAL SIZE 4
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001902
|
|
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 5
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001900
|
|
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 UNIVERSAL SIZE 5
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001900
|
|
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 8
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002639
|
|
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 UNIVERSAL SIZE 8
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002639
|
|
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 UNIVERSAL TIBIAL SZ 3
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001911
|
|
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 UNIVERSAL TIBIAL SZ 3
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001911
|
|
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 BASE TIBIAL UNI JOURNEY SZ3
|
Facility
|
OP
|
$3,852.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.00 |
| Max. Negotiated Rate |
$3,659.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cigna Commercial |
$3,274.20
|
| Rate for Payer: First Health Commercial |
$3,466.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,466.80
|
| Rate for Payer: GEHA Commercial |
$3,081.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,466.80
|
| Rate for Payer: Humana ChoiceCare |
$1,001.52
|
| Rate for Payer: Multiplan All |
$3,505.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,311.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,696.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,466.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,659.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,889.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,389.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$963.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,582.36
|
| Rate for Payer: Zelis Auto |
$1,540.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,926.00
|
|
|
IMPLT BASE TIBIAL UNI JOURNEY SZ3
|
Facility
|
IP
|
$3,852.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001797
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,540.80 |
| Max. Negotiated Rate |
$3,659.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,081.60
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cigna Commercial |
$3,274.20
|
| Rate for Payer: First Health Commercial |
$3,466.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,466.80
|
| Rate for Payer: GEHA Commercial |
$2,696.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,466.80
|
| Rate for Payer: Multiplan All |
$3,505.32
|
| Rate for Payer: OMNI Networks Commercial |
$2,696.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,466.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,659.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,889.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,582.36
|
| Rate for Payer: Zelis Auto |
$1,540.80
|
|
|
IMPLT BASE TIBIAL UNI RM/LL SZ4
|
Facility
|
IP
|
$3,852.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,540.80 |
| Max. Negotiated Rate |
$3,659.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,081.60
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cigna Commercial |
$3,274.20
|
| Rate for Payer: First Health Commercial |
$3,466.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,466.80
|
| Rate for Payer: GEHA Commercial |
$2,696.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,466.80
|
| Rate for Payer: Multiplan All |
$3,505.32
|
| Rate for Payer: OMNI Networks Commercial |
$2,696.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,466.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,659.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,889.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,582.36
|
| Rate for Payer: Zelis Auto |
$1,540.80
|
|
|
IMPLT BASE TIBIAL UNI RM/LL SZ4
|
Facility
|
OP
|
$3,852.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001798
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.00 |
| Max. Negotiated Rate |
$3,659.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Cigna Commercial |
$3,274.20
|
| Rate for Payer: First Health Commercial |
$3,466.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,466.80
|
| Rate for Payer: GEHA Commercial |
$3,081.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,466.80
|
| Rate for Payer: Humana ChoiceCare |
$1,001.52
|
| Rate for Payer: Multiplan All |
$3,505.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,311.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,696.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,466.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,659.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,889.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,389.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$963.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,582.36
|
| Rate for Payer: Zelis Auto |
$1,540.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,926.00
|
|
|
IMPLT BEARING HUMERAL 36MM +3
|
Facility
|
OP
|
$6,127.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,531.75 |
| Max. Negotiated Rate |
$5,820.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,676.20
|
| Rate for Payer: Cash Price |
$3,676.20
|
| Rate for Payer: Cash Price |
$3,676.20
|
| Rate for Payer: Cigna Commercial |
$5,207.95
|
| Rate for Payer: First Health Commercial |
$5,514.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,514.30
|
| Rate for Payer: GEHA Commercial |
$4,901.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,514.30
|
| Rate for Payer: Humana ChoiceCare |
$1,593.02
|
| Rate for Payer: Multiplan All |
$5,575.57
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,676.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,288.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,514.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,820.65
|
| Rate for Payer: Three Rivers Provider Network All |
$4,595.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,391.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,531.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,698.11
|
| Rate for Payer: Zelis Auto |
$2,450.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,063.50
|
|
|
IMPLT BEARING HUMERAL 36MM +3
|
Facility
|
IP
|
$6,127.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,450.80 |
| Max. Negotiated Rate |
$5,820.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,901.60
|
| Rate for Payer: Cash Price |
$3,676.20
|
| Rate for Payer: Cash Price |
$3,676.20
|
| Rate for Payer: Cigna Commercial |
$5,207.95
|
| Rate for Payer: First Health Commercial |
$5,514.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,514.30
|
| Rate for Payer: GEHA Commercial |
$4,288.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,514.30
|
| Rate for Payer: Multiplan All |
$5,575.57
|
| Rate for Payer: OMNI Networks Commercial |
$4,288.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,514.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,820.65
|
| Rate for Payer: Three Rivers Provider Network All |
$4,595.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,698.11
|
| Rate for Payer: Zelis Auto |
$2,450.80
|
|
|
IMPLT BEARING HUMERAL 36MM RETENTIVE
|
Facility
|
OP
|
$4,808.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,202.00 |
| Max. Negotiated Rate |
$4,567.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cigna Commercial |
$4,086.80
|
| Rate for Payer: First Health Commercial |
$4,327.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,327.20
|
| Rate for Payer: GEHA Commercial |
$3,846.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,327.20
|
| Rate for Payer: Humana ChoiceCare |
$1,250.08
|
| Rate for Payer: Multiplan All |
$4,375.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,884.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,365.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,327.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,567.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,606.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,231.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,202.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,471.44
|
| Rate for Payer: Zelis Auto |
$1,923.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,404.00
|
|
|
IMPLT BEARING HUMERAL 36MM RETENTIVE
|
Facility
|
IP
|
$4,808.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001912
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,923.20 |
| Max. Negotiated Rate |
$4,567.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,846.40
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cigna Commercial |
$4,086.80
|
| Rate for Payer: First Health Commercial |
$4,327.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,327.20
|
| Rate for Payer: GEHA Commercial |
$3,365.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,327.20
|
| Rate for Payer: Multiplan All |
$4,375.28
|
| Rate for Payer: OMNI Networks Commercial |
$3,365.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,327.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,567.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,606.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,471.44
|
| Rate for Payer: Zelis Auto |
$1,923.20
|
|
|
IMPLT BEARING HUMERAL 44/36MM+3
|
Facility
|
OP
|
$4,537.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.25 |
| Max. Negotiated Rate |
$4,310.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,722.20
|
| Rate for Payer: Cash Price |
$2,722.20
|
| Rate for Payer: Cash Price |
$2,722.20
|
| Rate for Payer: Cigna Commercial |
$3,856.45
|
| Rate for Payer: First Health Commercial |
$4,083.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,083.30
|
| Rate for Payer: GEHA Commercial |
$3,629.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,083.30
|
| Rate for Payer: Humana ChoiceCare |
$1,179.62
|
| Rate for Payer: Multiplan All |
$4,128.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,722.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,175.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,083.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,310.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,402.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,992.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,134.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,219.41
|
| Rate for Payer: Zelis Auto |
$1,814.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,268.50
|
|
|
IMPLT BEARING HUMERAL 44/36MM+3
|
Facility
|
IP
|
$4,537.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,814.80 |
| Max. Negotiated Rate |
$4,310.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,629.60
|
| Rate for Payer: Cash Price |
$2,722.20
|
| Rate for Payer: Cash Price |
$2,722.20
|
| Rate for Payer: Cigna Commercial |
$3,856.45
|
| Rate for Payer: First Health Commercial |
$4,083.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,083.30
|
| Rate for Payer: GEHA Commercial |
$3,175.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,083.30
|
| Rate for Payer: Multiplan All |
$4,128.67
|
| Rate for Payer: OMNI Networks Commercial |
$3,175.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,083.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,310.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,402.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,219.41
|
| Rate for Payer: Zelis Auto |
$1,814.80
|
|
|
IMPLT BEARING HUMERAL 44MM +36MM
|
Facility
|
IP
|
$6,851.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003123
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,740.40 |
| Max. Negotiated Rate |
$6,508.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,480.80
|
| Rate for Payer: Cash Price |
$4,110.60
|
| Rate for Payer: Cash Price |
$4,110.60
|
| Rate for Payer: Cigna Commercial |
$5,823.35
|
| Rate for Payer: First Health Commercial |
$6,165.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,165.90
|
| Rate for Payer: GEHA Commercial |
$4,795.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,165.90
|
| Rate for Payer: Multiplan All |
$6,234.41
|
| Rate for Payer: OMNI Networks Commercial |
$4,795.70
|
| Rate for Payer: One Health Plan PPO/POS |
$6,165.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,508.45
|
| Rate for Payer: Three Rivers Provider Network All |
$5,138.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,371.43
|
| Rate for Payer: Zelis Auto |
$2,740.40
|
|
|
IMPLT BEARING HUMERAL 44MM +36MM
|
Facility
|
OP
|
$6,851.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003123
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,712.75 |
| Max. Negotiated Rate |
$6,508.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,110.60
|
| Rate for Payer: Cash Price |
$4,110.60
|
| Rate for Payer: Cash Price |
$4,110.60
|
| Rate for Payer: Cigna Commercial |
$5,823.35
|
| Rate for Payer: First Health Commercial |
$6,165.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,165.90
|
| Rate for Payer: GEHA Commercial |
$5,480.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,165.90
|
| Rate for Payer: Humana ChoiceCare |
$1,781.26
|
| Rate for Payer: Multiplan All |
$6,234.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,110.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,795.70
|
| Rate for Payer: One Health Plan PPO/POS |
$6,165.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,508.45
|
| Rate for Payer: Three Rivers Provider Network All |
$5,138.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,028.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,712.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,371.43
|
| Rate for Payer: Zelis Auto |
$2,740.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,425.50
|
|
|
IMPLT BEARING HUMERAL 44MM #6
|
Facility
|
IP
|
$4,449.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001803
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,779.60 |
| Max. Negotiated Rate |
$4,226.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,559.20
|
| Rate for Payer: Cash Price |
$2,669.40
|
| Rate for Payer: Cash Price |
$2,669.40
|
| Rate for Payer: Cigna Commercial |
$3,781.65
|
| Rate for Payer: First Health Commercial |
$4,004.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,004.10
|
| Rate for Payer: GEHA Commercial |
$3,114.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,004.10
|
| Rate for Payer: Multiplan All |
$4,048.59
|
| Rate for Payer: OMNI Networks Commercial |
$3,114.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,004.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,226.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,336.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,137.57
|
| Rate for Payer: Zelis Auto |
$1,779.60
|
|
|
IMPLT BEARING HUMERAL 44MM #6
|
Facility
|
OP
|
$4,449.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001803
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,112.25 |
| Max. Negotiated Rate |
$4,226.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,669.40
|
| Rate for Payer: Cash Price |
$2,669.40
|
| Rate for Payer: Cash Price |
$2,669.40
|
| Rate for Payer: Cigna Commercial |
$3,781.65
|
| Rate for Payer: First Health Commercial |
$4,004.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,004.10
|
| Rate for Payer: GEHA Commercial |
$3,559.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,004.10
|
| Rate for Payer: Humana ChoiceCare |
$1,156.74
|
| Rate for Payer: Multiplan All |
$4,048.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,669.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,114.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,004.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,226.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,336.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,915.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,112.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,137.57
|
| Rate for Payer: Zelis Auto |
$1,779.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,224.50
|
|
|
IMPLT BEARING HUMERAL STANDARD 36MM
|
Facility
|
OP
|
$4,808.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,202.00 |
| Max. Negotiated Rate |
$4,567.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cigna Commercial |
$4,086.80
|
| Rate for Payer: First Health Commercial |
$4,327.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,327.20
|
| Rate for Payer: GEHA Commercial |
$3,846.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,327.20
|
| Rate for Payer: Humana ChoiceCare |
$1,250.08
|
| Rate for Payer: Multiplan All |
$4,375.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,884.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,365.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,327.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,567.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,606.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,231.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,202.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,471.44
|
| Rate for Payer: Zelis Auto |
$1,923.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,404.00
|
|
|
IMPLT BEARING HUMERAL STANDARD 36MM
|
Facility
|
IP
|
$4,808.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,923.20 |
| Max. Negotiated Rate |
$4,567.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,846.40
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cash Price |
$2,884.80
|
| Rate for Payer: Cigna Commercial |
$4,086.80
|
| Rate for Payer: First Health Commercial |
$4,327.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,327.20
|
| Rate for Payer: GEHA Commercial |
$3,365.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,327.20
|
| Rate for Payer: Multiplan All |
$4,375.28
|
| Rate for Payer: OMNI Networks Commercial |
$3,365.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,327.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,567.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,606.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,471.44
|
| Rate for Payer: Zelis Auto |
$1,923.20
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ4
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
