|
IMPLT BIO-COMP SWVLK 3.5 X 15.8MM
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7004285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,850.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,800.00
|
| 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 |
$2,400.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,700.00
|
| Rate for Payer: Humana ChoiceCare |
$780.00
|
| Rate for Payer: Multiplan All |
$2,730.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,800.00
|
| 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: TriWest Veterans Administration/VAPC3 |
$2,640.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$750.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,790.00
|
| Rate for Payer: Zelis Auto |
$1,200.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,500.00
|
|
|
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 4.75X19.1MM
|
Facility
|
IP
|
$2,807.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003306
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,122.80 |
| Max. Negotiated Rate |
$2,666.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,245.60
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cigna Commercial |
$2,385.95
|
| Rate for Payer: First Health Commercial |
$2,526.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,526.30
|
| Rate for Payer: GEHA Commercial |
$1,964.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,526.30
|
| Rate for Payer: Multiplan All |
$2,554.37
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,526.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,666.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,105.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,610.51
|
| Rate for Payer: Zelis Auto |
$1,122.80
|
|
|
IMPLT BIO-COMP SWVLK 4.75X19.1MM
|
Facility
|
OP
|
$2,807.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003306
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$701.75 |
| Max. Negotiated Rate |
$2,666.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,684.20
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cash Price |
$1,684.20
|
| Rate for Payer: Cigna Commercial |
$2,385.95
|
| Rate for Payer: First Health Commercial |
$2,526.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,526.30
|
| Rate for Payer: GEHA Commercial |
$2,245.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,526.30
|
| Rate for Payer: Humana ChoiceCare |
$729.82
|
| Rate for Payer: Multiplan All |
$2,554.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,684.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,964.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,526.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,666.65
|
| Rate for Payer: Three Rivers Provider Network All |
$2,105.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,470.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$701.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,610.51
|
| Rate for Payer: Zelis Auto |
$1,122.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,403.50
|
|
|
IMPLT BIO-COMP SWVLK 4.75X24.5MM
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,035.20 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,070.40
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$1,811.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
|
|
IMPLT BIO-COMP SWVLK 4.75X24.5MM
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.00 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$2,070.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Humana ChoiceCare |
$672.88
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,552.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,277.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$647.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,294.00
|
|
|
IMPLT BIOPRO HEMI MED/LG
|
Facility
|
OP
|
$4,035.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,008.75 |
| Max. Negotiated Rate |
$3,833.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,421.00
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cigna Commercial |
$3,429.75
|
| Rate for Payer: First Health Commercial |
$3,631.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,631.50
|
| Rate for Payer: GEHA Commercial |
$3,228.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,631.50
|
| Rate for Payer: Humana ChoiceCare |
$1,049.10
|
| Rate for Payer: Multiplan All |
$3,671.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,421.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,824.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,631.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,833.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,026.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,550.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,008.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,752.55
|
| Rate for Payer: Zelis Auto |
$1,614.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,017.50
|
|
|
IMPLT BIOPRO HEMI MED/LG
|
Facility
|
IP
|
$4,035.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001869
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,614.00 |
| Max. Negotiated Rate |
$3,833.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,228.00
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cash Price |
$2,421.00
|
| Rate for Payer: Cigna Commercial |
$3,429.75
|
| Rate for Payer: First Health Commercial |
$3,631.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,631.50
|
| Rate for Payer: GEHA Commercial |
$2,824.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,631.50
|
| Rate for Payer: Multiplan All |
$3,671.85
|
| Rate for Payer: OMNI Networks Commercial |
$2,824.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,631.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,833.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,026.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,752.55
|
| Rate for Payer: Zelis Auto |
$1,614.00
|
|
|
IMPLT BIOPRO LG 23MM
|
Facility
|
OP
|
$6,090.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.50 |
| Max. Negotiated Rate |
$5,785.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cigna Commercial |
$5,176.50
|
| Rate for Payer: First Health Commercial |
$5,481.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,481.00
|
| Rate for Payer: GEHA Commercial |
$4,872.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,481.00
|
| Rate for Payer: Humana ChoiceCare |
$1,583.40
|
| Rate for Payer: Multiplan All |
$5,541.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,654.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,263.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,481.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,785.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,359.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,522.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,663.70
|
| Rate for Payer: Zelis Auto |
$2,436.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,045.00
|
|
|
IMPLT BIOPRO LG 23MM
|
Facility
|
IP
|
$6,090.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,436.00 |
| Max. Negotiated Rate |
$5,785.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,872.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cash Price |
$3,654.00
|
| Rate for Payer: Cigna Commercial |
$5,176.50
|
| Rate for Payer: First Health Commercial |
$5,481.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,481.00
|
| Rate for Payer: GEHA Commercial |
$4,263.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,481.00
|
| Rate for Payer: Multiplan All |
$5,541.90
|
| Rate for Payer: OMNI Networks Commercial |
$4,263.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,481.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,785.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,567.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,663.70
|
| Rate for Payer: Zelis Auto |
$2,436.00
|
|
|
IMPLT BIOPRO S.T. 10MM
|
Facility
|
IP
|
$4,568.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,827.20 |
| Max. Negotiated Rate |
$4,339.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,654.40
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cigna Commercial |
$3,882.80
|
| Rate for Payer: First Health Commercial |
$4,111.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,111.20
|
| Rate for Payer: GEHA Commercial |
$3,197.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,111.20
|
| Rate for Payer: Multiplan All |
$4,156.88
|
| Rate for Payer: OMNI Networks Commercial |
$3,197.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,111.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,339.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,426.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,248.24
|
| Rate for Payer: Zelis Auto |
$1,827.20
|
|
|
IMPLT BIOPRO S.T. 10MM
|
Facility
|
OP
|
$4,568.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.00 |
| Max. Negotiated Rate |
$4,339.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cash Price |
$2,740.80
|
| Rate for Payer: Cigna Commercial |
$3,882.80
|
| Rate for Payer: First Health Commercial |
$4,111.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,111.20
|
| Rate for Payer: GEHA Commercial |
$3,654.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,111.20
|
| Rate for Payer: Humana ChoiceCare |
$1,187.68
|
| Rate for Payer: Multiplan All |
$4,156.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,740.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,197.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,111.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,339.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,426.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,019.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,142.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,248.24
|
| Rate for Payer: Zelis Auto |
$1,827.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,284.00
|
|
|
IMPLT BLOCK HALF AUGMENT TIBIAL #4
|
Facility
|
IP
|
$3,799.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,519.60 |
| Max. Negotiated Rate |
$3,609.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,039.20
|
| Rate for Payer: Cash Price |
$2,279.40
|
| Rate for Payer: Cash Price |
$2,279.40
|
| Rate for Payer: Cigna Commercial |
$3,229.15
|
| Rate for Payer: First Health Commercial |
$3,419.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,419.10
|
| Rate for Payer: GEHA Commercial |
$2,659.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,419.10
|
| Rate for Payer: Multiplan All |
$3,457.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,659.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,419.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,609.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,849.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,533.07
|
| Rate for Payer: Zelis Auto |
$1,519.60
|
|
|
IMPLT BLOCK HALF AUGMENT TIBIAL #4
|
Facility
|
OP
|
$3,799.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$949.75 |
| Max. Negotiated Rate |
$3,609.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,279.40
|
| Rate for Payer: Cash Price |
$2,279.40
|
| Rate for Payer: Cash Price |
$2,279.40
|
| Rate for Payer: Cigna Commercial |
$3,229.15
|
| Rate for Payer: First Health Commercial |
$3,419.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,419.10
|
| Rate for Payer: GEHA Commercial |
$3,039.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,419.10
|
| Rate for Payer: Humana ChoiceCare |
$987.74
|
| Rate for Payer: Multiplan All |
$3,457.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,279.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,659.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,419.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,609.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,849.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,343.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$949.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,533.07
|
| Rate for Payer: Zelis Auto |
$1,519.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,899.50
|
|
|
IMPLT BLOCK HALF TIBIAL AUGMENT SIZE 5
|
Facility
|
OP
|
$3,609.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001805
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$902.25 |
| Max. Negotiated Rate |
$3,428.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cigna Commercial |
$3,067.65
|
| Rate for Payer: First Health Commercial |
$3,248.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,248.10
|
| Rate for Payer: GEHA Commercial |
$2,887.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,248.10
|
| Rate for Payer: Humana ChoiceCare |
$938.34
|
| Rate for Payer: Multiplan All |
$3,284.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,165.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,526.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,248.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,428.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,706.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,175.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$902.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,356.37
|
| Rate for Payer: Zelis Auto |
$1,443.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,804.50
|
|
|
IMPLT BLOCK HALF TIBIAL AUGMENT SIZE 5
|
Facility
|
IP
|
$3,609.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001805
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.60 |
| Max. Negotiated Rate |
$3,428.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,887.20
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cash Price |
$2,165.40
|
| Rate for Payer: Cigna Commercial |
$3,067.65
|
| Rate for Payer: First Health Commercial |
$3,248.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,248.10
|
| Rate for Payer: GEHA Commercial |
$2,526.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,248.10
|
| Rate for Payer: Multiplan All |
$3,284.19
|
| Rate for Payer: OMNI Networks Commercial |
$2,526.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,248.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,428.55
|
| Rate for Payer: Three Rivers Provider Network All |
$2,706.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,356.37
|
| Rate for Payer: Zelis Auto |
$1,443.60
|
|
|
IMPLT BONE FIX SYS 1.6MM
|
Facility
|
IP
|
$1,228.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$491.20 |
| Max. Negotiated Rate |
$1,166.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$982.40
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$1,043.80
|
| Rate for Payer: First Health Commercial |
$1,105.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,105.20
|
| Rate for Payer: GEHA Commercial |
$859.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,105.20
|
| Rate for Payer: Multiplan All |
$1,117.48
|
| Rate for Payer: OMNI Networks Commercial |
$859.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,105.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,166.60
|
| Rate for Payer: Three Rivers Provider Network All |
$921.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,142.04
|
| Rate for Payer: Zelis Auto |
$491.20
|
|
|
IMPLT BONE FIX SYS 1.6MM
|
Facility
|
OP
|
$1,228.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$307.00 |
| Max. Negotiated Rate |
$1,166.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$736.80
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$1,043.80
|
| Rate for Payer: First Health Commercial |
$1,105.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,105.20
|
| Rate for Payer: GEHA Commercial |
$982.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,105.20
|
| Rate for Payer: Humana ChoiceCare |
$319.28
|
| Rate for Payer: Multiplan All |
$1,117.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$736.80
|
| Rate for Payer: OMNI Networks Commercial |
$859.60
|
| Rate for Payer: One Health Plan PPO/POS |
$1,105.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,166.60
|
| Rate for Payer: Three Rivers Provider Network All |
$921.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,080.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$307.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,142.04
|
| Rate for Payer: Zelis Auto |
$491.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$614.00
|
|
|
IMPLT BONE MORPH LG
|
Facility
|
IP
|
$18,757.00
|
|
|
Service Code
|
CPT 55874
|
| Hospital Charge Code |
7006526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,502.80 |
| Max. Negotiated Rate |
$17,819.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,005.60
|
| Rate for Payer: Cash Price |
$11,254.20
|
| Rate for Payer: Cash Price |
$11,254.20
|
| Rate for Payer: Cigna Commercial |
$15,943.45
|
| Rate for Payer: First Health Commercial |
$16,881.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16,881.30
|
| Rate for Payer: GEHA Commercial |
$13,129.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16,881.30
|
| Rate for Payer: Multiplan All |
$17,068.87
|
| Rate for Payer: OMNI Networks Commercial |
$13,129.90
|
| Rate for Payer: One Health Plan PPO/POS |
$16,881.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17,819.15
|
| Rate for Payer: Three Rivers Provider Network All |
$14,067.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17,444.01
|
| Rate for Payer: Zelis Auto |
$7,502.80
|
|
|
IMPLT BONE MORPH LG
|
Facility
|
OP
|
$18,757.00
|
|
|
Service Code
|
CPT 55874
|
| Hospital Charge Code |
7006526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,103.03 |
| Max. Negotiated Rate |
$17,819.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5,558.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11,254.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5,558.65
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4,403.57
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$4,827.10
|
| Rate for Payer: Cash Price |
$11,254.20
|
| Rate for Payer: Cash Price |
$11,254.20
|
| Rate for Payer: Cash Price |
$11,254.20
|
| Rate for Payer: Cigna Commercial |
$15,943.45
|
| Rate for Payer: First Health Commercial |
$16,881.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16,881.30
|
| Rate for Payer: GEHA Commercial |
$15,005.60
|
| Rate for Payer: GEHA Medicare |
$4,827.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16,881.30
|
| Rate for Payer: Humana ChoiceCare |
$5,309.81
|
| Rate for Payer: Humana Medicare Advantage |
$4,827.10
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$8,109.53
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4,493.25
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$4,827.10
|
| Rate for Payer: Multiplan All |
$17,068.87
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,206.07
|
| Rate for Payer: OMNI Networks Commercial |
$13,129.90
|
| Rate for Payer: One Health Plan PPO/POS |
$16,881.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5,188.08
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4,493.25
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$4,827.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17,819.15
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$9,654.20
|
| Rate for Payer: Three Rivers Provider Network All |
$14,067.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,730.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,493.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,827.10
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17,444.01
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$4,827.10
|
| Rate for Payer: Zelis Auto |
$7,502.80
|
| Rate for Payer: Zelis Medicare |
$4,103.03
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,792.52
|
|
|
IMPLT BONE MORPH PRO MD
|
Facility
|
OP
|
$15,980.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,995.00 |
| Max. Negotiated Rate |
$15,181.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,588.00
|
| Rate for Payer: Cash Price |
$9,588.00
|
| Rate for Payer: Cash Price |
$9,588.00
|
| Rate for Payer: Cigna Commercial |
$13,583.00
|
| Rate for Payer: First Health Commercial |
$14,382.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,382.00
|
| Rate for Payer: GEHA Commercial |
$12,784.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,382.00
|
| Rate for Payer: Humana ChoiceCare |
$4,154.80
|
| Rate for Payer: Multiplan All |
$14,541.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,588.00
|
| Rate for Payer: OMNI Networks Commercial |
$11,186.00
|
| Rate for Payer: One Health Plan PPO/POS |
$14,382.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,181.00
|
| Rate for Payer: Three Rivers Provider Network All |
$11,985.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14,062.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,995.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14,861.40
|
| Rate for Payer: Zelis Auto |
$6,392.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,990.00
|
|
|
IMPLT BONE MORPH PRO MD
|
Facility
|
IP
|
$15,980.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,392.00 |
| Max. Negotiated Rate |
$15,181.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,784.00
|
| Rate for Payer: Cash Price |
$9,588.00
|
| Rate for Payer: Cash Price |
$9,588.00
|
| Rate for Payer: Cigna Commercial |
$13,583.00
|
| Rate for Payer: First Health Commercial |
$14,382.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,382.00
|
| Rate for Payer: GEHA Commercial |
$11,186.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,382.00
|
| Rate for Payer: Multiplan All |
$14,541.80
|
| Rate for Payer: OMNI Networks Commercial |
$11,186.00
|
| Rate for Payer: One Health Plan PPO/POS |
$14,382.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,181.00
|
| Rate for Payer: Three Rivers Provider Network All |
$11,985.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14,861.40
|
| Rate for Payer: Zelis Auto |
$6,392.00
|
|
|
IMPLT BONE MORPH PRO SM
|
Facility
|
OP
|
$11,690.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,922.50 |
| Max. Negotiated Rate |
$11,105.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,014.00
|
| Rate for Payer: Cash Price |
$7,014.00
|
| Rate for Payer: Cash Price |
$7,014.00
|
| Rate for Payer: Cigna Commercial |
$9,936.50
|
| Rate for Payer: First Health Commercial |
$10,521.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,521.00
|
| Rate for Payer: GEHA Commercial |
$9,352.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,521.00
|
| Rate for Payer: Humana ChoiceCare |
$3,039.40
|
| Rate for Payer: Multiplan All |
$10,637.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,014.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,183.00
|
| Rate for Payer: One Health Plan PPO/POS |
$10,521.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,105.50
|
| Rate for Payer: Three Rivers Provider Network All |
$8,767.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,287.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,922.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,871.70
|
| Rate for Payer: Zelis Auto |
$4,676.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,845.00
|
|
|
IMPLT BONE MORPH PRO SM
|
Facility
|
IP
|
$11,690.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,676.00 |
| Max. Negotiated Rate |
$11,105.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,352.00
|
| Rate for Payer: Cash Price |
$7,014.00
|
| Rate for Payer: Cash Price |
$7,014.00
|
| Rate for Payer: Cigna Commercial |
$9,936.50
|
| Rate for Payer: First Health Commercial |
$10,521.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,521.00
|
| Rate for Payer: GEHA Commercial |
$8,183.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,521.00
|
| Rate for Payer: Multiplan All |
$10,637.90
|
| Rate for Payer: OMNI Networks Commercial |
$8,183.00
|
| Rate for Payer: One Health Plan PPO/POS |
$10,521.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,105.50
|
| Rate for Payer: Three Rivers Provider Network All |
$8,767.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,871.70
|
| Rate for Payer: Zelis Auto |
$4,676.00
|
|
|
IMPLT BONE SCREW HW 16MM 1152-16
|
Facility
|
IP
|
$2,159.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000212
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$863.60 |
| Max. Negotiated Rate |
$2,051.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,727.20
|
| Rate for Payer: Cash Price |
$1,295.40
|
| Rate for Payer: Cash Price |
$1,295.40
|
| Rate for Payer: Cigna Commercial |
$1,835.15
|
| Rate for Payer: First Health Commercial |
$1,943.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,943.10
|
| Rate for Payer: GEHA Commercial |
$1,511.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,943.10
|
| Rate for Payer: Multiplan All |
$1,964.69
|
| Rate for Payer: OMNI Networks Commercial |
$1,511.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,943.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,051.05
|
| Rate for Payer: Three Rivers Provider Network All |
$1,619.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,007.87
|
| Rate for Payer: Zelis Auto |
$863.60
|
|
