|
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
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ4
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ4
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008035
|
|
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
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ4
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008039
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ4
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ5
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ5
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003416
|
|
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
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ5
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003372
|
|
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
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ5
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ6
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003242
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL - CS SZ6
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003242
|
|
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
|
|
|
IMPLT BEARING INSERT TIBIAL SZ6
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001915
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING INSERT TIBIAL SZ6
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001915
|
|
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
|
|
|
IMPLT BEARING TIBIAL AS 55MM 75MM
|
Facility
|
OP
|
$8,739.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.75 |
| Max. Negotiated Rate |
$8,302.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,243.40
|
| Rate for Payer: Cash Price |
$5,243.40
|
| Rate for Payer: Cash Price |
$5,243.40
|
| Rate for Payer: Cigna Commercial |
$7,428.15
|
| Rate for Payer: First Health Commercial |
$7,865.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,865.10
|
| Rate for Payer: GEHA Commercial |
$6,991.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,865.10
|
| Rate for Payer: Humana ChoiceCare |
$2,272.14
|
| Rate for Payer: Multiplan All |
$7,952.49
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,243.40
|
| Rate for Payer: OMNI Networks Commercial |
$6,117.30
|
| Rate for Payer: One Health Plan PPO/POS |
$7,865.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,302.05
|
| Rate for Payer: Three Rivers Provider Network All |
$6,554.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,690.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,184.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,127.27
|
| Rate for Payer: Zelis Auto |
$3,495.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,369.50
|
|
|
IMPLT BEARING TIBIAL AS 55MM 75MM
|
Facility
|
IP
|
$8,739.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,495.60 |
| Max. Negotiated Rate |
$8,302.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,991.20
|
| Rate for Payer: Cash Price |
$5,243.40
|
| Rate for Payer: Cash Price |
$5,243.40
|
| Rate for Payer: Cigna Commercial |
$7,428.15
|
| Rate for Payer: First Health Commercial |
$7,865.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,865.10
|
| Rate for Payer: GEHA Commercial |
$6,117.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,865.10
|
| Rate for Payer: Multiplan All |
$7,952.49
|
| Rate for Payer: OMNI Networks Commercial |
$6,117.30
|
| Rate for Payer: One Health Plan PPO/POS |
$7,865.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,302.05
|
| Rate for Payer: Three Rivers Provider Network All |
$6,554.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,127.27
|
| Rate for Payer: Zelis Auto |
$3,495.60
|
|
|
IMPLT BEARING TIBIAL INSERT - CS SIZE 8
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003247
|
|
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
|
|
|
IMPLT BEARING TIBIAL INSERT - CS SIZE 8
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING TIBIAL INSERT SIZE 8
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001804
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| 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 |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| 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: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT BEARING TIBIAL INSERT SIZE 8
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001804
|
|
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
|
|
|
IMPLT BEARING VANGUARD CONSTRAINED
|
Facility
|
OP
|
$8,261.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.25 |
| Max. Negotiated Rate |
$7,847.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,956.60
|
| Rate for Payer: Cash Price |
$4,956.60
|
| Rate for Payer: Cash Price |
$4,956.60
|
| Rate for Payer: Cigna Commercial |
$7,021.85
|
| Rate for Payer: First Health Commercial |
$7,434.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,434.90
|
| Rate for Payer: GEHA Commercial |
$6,608.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,434.90
|
| Rate for Payer: Humana ChoiceCare |
$2,147.86
|
| Rate for Payer: Multiplan All |
$7,517.51
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,956.60
|
| Rate for Payer: OMNI Networks Commercial |
$5,782.70
|
| Rate for Payer: One Health Plan PPO/POS |
$7,434.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,847.95
|
| Rate for Payer: Three Rivers Provider Network All |
$6,195.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,269.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,065.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,682.73
|
| Rate for Payer: Zelis Auto |
$3,304.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,130.50
|
|
|
IMPLT BEARING VANGUARD CONSTRAINED
|
Facility
|
IP
|
$8,261.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,304.40 |
| Max. Negotiated Rate |
$7,847.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,608.80
|
| Rate for Payer: Cash Price |
$4,956.60
|
| Rate for Payer: Cash Price |
$4,956.60
|
| Rate for Payer: Cigna Commercial |
$7,021.85
|
| Rate for Payer: First Health Commercial |
$7,434.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,434.90
|
| Rate for Payer: GEHA Commercial |
$5,782.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,434.90
|
| Rate for Payer: Multiplan All |
$7,517.51
|
| Rate for Payer: OMNI Networks Commercial |
$5,782.70
|
| Rate for Payer: One Health Plan PPO/POS |
$7,434.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,847.95
|
| Rate for Payer: Three Rivers Provider Network All |
$6,195.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,682.73
|
| Rate for Payer: Zelis Auto |
$3,304.40
|
|
|
IMPLT BIOCOMPOSITE SW/LK
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.50 |
| Max. Negotiated Rate |
$1,757.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,110.00
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cigna Commercial |
$1,572.50
|
| Rate for Payer: First Health Commercial |
$1,665.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,665.00
|
| Rate for Payer: GEHA Commercial |
$1,480.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,665.00
|
| Rate for Payer: Humana ChoiceCare |
$481.00
|
| Rate for Payer: Multiplan All |
$1,683.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,110.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,295.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,665.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,757.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,387.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,628.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$462.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,720.50
|
| Rate for Payer: Zelis Auto |
$740.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$925.00
|
|
|
IMPLT BIOCOMPOSITE SW/LK
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$740.00 |
| Max. Negotiated Rate |
$1,757.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,480.00
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cash Price |
$1,110.00
|
| Rate for Payer: Cigna Commercial |
$1,572.50
|
| Rate for Payer: First Health Commercial |
$1,665.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,665.00
|
| Rate for Payer: GEHA Commercial |
$1,295.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,665.00
|
| Rate for Payer: Multiplan All |
$1,683.50
|
| Rate for Payer: OMNI Networks Commercial |
$1,295.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,665.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,757.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,387.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,720.50
|
| Rate for Payer: Zelis Auto |
$740.00
|
|
|
IMPLT BIO-COMP SWVLK 3.5 X 15.8MM
|
Facility
|
OP
|
$3,038.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7004284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$759.50 |
| Max. Negotiated Rate |
$2,886.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,822.80
|
| Rate for Payer: Cash Price |
$1,822.80
|
| Rate for Payer: Cash Price |
$1,822.80
|
| Rate for Payer: Cigna Commercial |
$2,582.30
|
| Rate for Payer: First Health Commercial |
$2,734.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,734.20
|
| Rate for Payer: GEHA Commercial |
$2,430.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,734.20
|
| Rate for Payer: Humana ChoiceCare |
$789.88
|
| Rate for Payer: Multiplan All |
$2,764.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,822.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,126.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,734.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,886.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,278.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,673.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$759.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,825.34
|
| Rate for Payer: Zelis Auto |
$1,215.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,519.00
|
|
|
IMPLT BIO-COMP SWVLK 3.5 X 15.8MM
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7004285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,850.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,400.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,550.00
|
| Rate for Payer: First Health Commercial |
$2,700.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,700.00
|
| Rate for Payer: GEHA Commercial |
$2,100.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,700.00
|
| Rate for Payer: Multiplan All |
$2,730.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,100.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,700.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,850.00
|
| Rate for Payer: Three Rivers Provider Network All |
$2,250.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,790.00
|
| Rate for Payer: Zelis Auto |
$1,200.00
|
|
