|
IMPLT COMPONENT FEMORAL POROUS
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL POROUS
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001827
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL POROUS SZ15
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001940
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL POROUS SZ15
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001940
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL RIGHT SIZE 6
|
Facility
|
OP
|
$7,552.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,888.00 |
| Max. Negotiated Rate |
$7,174.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,531.20
|
| Rate for Payer: Cash Price |
$4,531.20
|
| Rate for Payer: Cash Price |
$4,531.20
|
| Rate for Payer: Cigna Commercial |
$6,419.20
|
| Rate for Payer: First Health Commercial |
$6,796.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,796.80
|
| Rate for Payer: GEHA Commercial |
$6,041.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,796.80
|
| Rate for Payer: Humana ChoiceCare |
$1,963.52
|
| Rate for Payer: Multiplan All |
$6,872.32
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,531.20
|
| Rate for Payer: OMNI Networks Commercial |
$5,286.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,796.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,174.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,664.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,645.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,888.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,023.36
|
| Rate for Payer: Zelis Auto |
$3,020.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,776.00
|
|
|
IMPLT COMPONENT FEMORAL RIGHT SIZE 6
|
Facility
|
IP
|
$7,552.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,020.80 |
| Max. Negotiated Rate |
$7,174.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,041.60
|
| Rate for Payer: Cash Price |
$4,531.20
|
| Rate for Payer: Cash Price |
$4,531.20
|
| Rate for Payer: Cigna Commercial |
$6,419.20
|
| Rate for Payer: First Health Commercial |
$6,796.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,796.80
|
| Rate for Payer: GEHA Commercial |
$5,286.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,796.80
|
| Rate for Payer: Multiplan All |
$6,872.32
|
| Rate for Payer: OMNI Networks Commercial |
$5,286.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,796.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,174.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,664.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,023.36
|
| Rate for Payer: Zelis Auto |
$3,020.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 11
|
Facility
|
OP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001814
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,191.25 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Humana ChoiceCare |
$1,238.90
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,859.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,193.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,191.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,382.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 11
|
Facility
|
IP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001814
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.00 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,812.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,335.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 12
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001833
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 12
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 12
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001833
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 12
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001822
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 13
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 13
|
Facility
|
OP
|
$5,329.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.25 |
| Max. Negotiated Rate |
$5,062.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,197.40
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cigna Commercial |
$4,529.65
|
| Rate for Payer: First Health Commercial |
$4,796.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,796.10
|
| Rate for Payer: GEHA Commercial |
$4,263.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,796.10
|
| Rate for Payer: Humana ChoiceCare |
$1,385.54
|
| Rate for Payer: Multiplan All |
$4,849.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,197.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,730.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,796.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,062.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,996.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,689.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,332.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,955.97
|
| Rate for Payer: Zelis Auto |
$2,131.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,664.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 13
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 13
|
Facility
|
IP
|
$5,329.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001823
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.60 |
| Max. Negotiated Rate |
$5,062.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,263.20
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cigna Commercial |
$4,529.65
|
| Rate for Payer: First Health Commercial |
$4,796.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,796.10
|
| Rate for Payer: GEHA Commercial |
$3,730.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,796.10
|
| Rate for Payer: Multiplan All |
$4,849.39
|
| Rate for Payer: OMNI Networks Commercial |
$3,730.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,796.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,062.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,996.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,955.97
|
| Rate for Payer: Zelis Auto |
$2,131.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
IP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.00 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,812.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,335.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
OP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001923
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$5,651.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Humana ChoiceCare |
$1,836.64
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,238.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,216.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,766.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,532.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001828
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
IP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.00 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,812.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,335.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
OP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,191.25 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Humana ChoiceCare |
$1,238.90
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,859.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,193.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,191.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,382.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
IP
|
$7,064.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001923
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,825.60 |
| Max. Negotiated Rate |
$6,710.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,651.20
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cash Price |
$4,238.40
|
| Rate for Payer: Cigna Commercial |
$6,004.40
|
| Rate for Payer: First Health Commercial |
$6,357.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,357.60
|
| Rate for Payer: GEHA Commercial |
$4,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,357.60
|
| Rate for Payer: Multiplan All |
$6,428.24
|
| Rate for Payer: OMNI Networks Commercial |
$4,944.80
|
| Rate for Payer: One Health Plan PPO/POS |
$6,357.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,710.80
|
| Rate for Payer: Three Rivers Provider Network All |
$5,298.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,569.52
|
| Rate for Payer: Zelis Auto |
$2,825.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 14
|
Facility
|
OP
|
$4,765.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,191.25 |
| Max. Negotiated Rate |
$4,526.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cash Price |
$2,859.00
|
| Rate for Payer: Cigna Commercial |
$4,050.25
|
| Rate for Payer: First Health Commercial |
$4,288.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,288.50
|
| Rate for Payer: GEHA Commercial |
$3,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,288.50
|
| Rate for Payer: Humana ChoiceCare |
$1,238.90
|
| Rate for Payer: Multiplan All |
$4,336.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,859.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,335.50
|
| Rate for Payer: One Health Plan PPO/POS |
$4,288.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,526.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,573.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,193.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,191.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,431.45
|
| Rate for Payer: Zelis Auto |
$1,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,382.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 15
|
Facility
|
IP
|
$5,329.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.60 |
| Max. Negotiated Rate |
$5,062.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,263.20
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cash Price |
$3,197.40
|
| Rate for Payer: Cigna Commercial |
$4,529.65
|
| Rate for Payer: First Health Commercial |
$4,796.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,796.10
|
| Rate for Payer: GEHA Commercial |
$3,730.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,796.10
|
| Rate for Payer: Multiplan All |
$4,849.39
|
| Rate for Payer: OMNI Networks Commercial |
$3,730.30
|
| Rate for Payer: One Health Plan PPO/POS |
$4,796.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,062.55
|
| Rate for Payer: Three Rivers Provider Network All |
$3,996.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,955.97
|
| Rate for Payer: Zelis Auto |
$2,131.60
|
|
