|
IMPLT COMPONENT FEMORAL SIZE 15
|
Facility
|
OP
|
$5,329.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001829
|
|
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 2
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,884.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Humana ChoiceCare |
$1,587.30
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,663.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,372.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,526.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,052.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 2
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.00 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,884.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,273.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE#2
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,884.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Humana ChoiceCare |
$1,587.30
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,663.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,372.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,526.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,052.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE#2
|
Facility
|
OP
|
$7,308.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,827.00 |
| Max. Negotiated Rate |
$6,942.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,384.80
|
| Rate for Payer: Cash Price |
$4,384.80
|
| Rate for Payer: Cash Price |
$4,384.80
|
| Rate for Payer: Cigna Commercial |
$6,211.80
|
| Rate for Payer: First Health Commercial |
$6,577.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,577.20
|
| Rate for Payer: GEHA Commercial |
$5,846.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,577.20
|
| Rate for Payer: Humana ChoiceCare |
$1,900.08
|
| Rate for Payer: Multiplan All |
$6,650.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,384.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,115.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,577.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,942.60
|
| Rate for Payer: Three Rivers Provider Network All |
$5,481.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,431.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,827.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,796.44
|
| Rate for Payer: Zelis Auto |
$2,923.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,654.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE#2
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.00 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,884.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,273.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE#2
|
Facility
|
IP
|
$7,308.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,923.20 |
| Max. Negotiated Rate |
$6,942.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,846.40
|
| Rate for Payer: Cash Price |
$4,384.80
|
| Rate for Payer: Cash Price |
$4,384.80
|
| Rate for Payer: Cigna Commercial |
$6,211.80
|
| Rate for Payer: First Health Commercial |
$6,577.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,577.20
|
| Rate for Payer: GEHA Commercial |
$5,115.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,577.20
|
| Rate for Payer: Multiplan All |
$6,650.28
|
| Rate for Payer: OMNI Networks Commercial |
$5,115.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,577.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,942.60
|
| Rate for Payer: Three Rivers Provider Network All |
$5,481.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,796.44
|
| Rate for Payer: Zelis Auto |
$2,923.20
|
|
|
IMPLT COMPONENT FEMORAL SIZE3
|
Facility
|
OP
|
$8,748.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,187.00 |
| Max. Negotiated Rate |
$8,310.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,248.80
|
| Rate for Payer: Cash Price |
$5,248.80
|
| Rate for Payer: Cash Price |
$5,248.80
|
| Rate for Payer: Cigna Commercial |
$7,435.80
|
| Rate for Payer: First Health Commercial |
$7,873.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,873.20
|
| Rate for Payer: GEHA Commercial |
$6,998.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,873.20
|
| Rate for Payer: Humana ChoiceCare |
$2,274.48
|
| Rate for Payer: Multiplan All |
$7,960.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,248.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,123.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,873.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,310.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,561.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,698.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,187.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,135.64
|
| Rate for Payer: Zelis Auto |
$3,499.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,374.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE3
|
Facility
|
IP
|
$8,748.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.20 |
| Max. Negotiated Rate |
$8,310.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,998.40
|
| Rate for Payer: Cash Price |
$5,248.80
|
| Rate for Payer: Cash Price |
$5,248.80
|
| Rate for Payer: Cigna Commercial |
$7,435.80
|
| Rate for Payer: First Health Commercial |
$7,873.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,873.20
|
| Rate for Payer: GEHA Commercial |
$6,123.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,873.20
|
| Rate for Payer: Multiplan All |
$7,960.68
|
| Rate for Payer: OMNI Networks Commercial |
$6,123.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,873.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,310.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,561.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,135.64
|
| Rate for Payer: Zelis Auto |
$3,499.20
|
|
|
IMPLT COMPONENT FEMORAL SIZE 3 RM/LL
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.50 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,993.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Humana ChoiceCare |
$1,622.92
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,745.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,492.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,560.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,121.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 3 RM/LL
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.80 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,993.60
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,369.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4
|
Facility
|
IP
|
$6,699.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,679.60 |
| Max. Negotiated Rate |
$6,364.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,359.20
|
| Rate for Payer: Cash Price |
$4,019.40
|
| Rate for Payer: Cash Price |
$4,019.40
|
| Rate for Payer: Cigna Commercial |
$5,694.15
|
| Rate for Payer: First Health Commercial |
$6,029.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,029.10
|
| Rate for Payer: GEHA Commercial |
$4,689.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,029.10
|
| Rate for Payer: Multiplan All |
$6,096.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,689.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,029.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,364.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,024.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,230.07
|
| Rate for Payer: Zelis Auto |
$2,679.60
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4
|
Facility
|
OP
|
$6,699.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001830
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.75 |
| Max. Negotiated Rate |
$6,364.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,019.40
|
| Rate for Payer: Cash Price |
$4,019.40
|
| Rate for Payer: Cash Price |
$4,019.40
|
| Rate for Payer: Cigna Commercial |
$5,694.15
|
| Rate for Payer: First Health Commercial |
$6,029.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,029.10
|
| Rate for Payer: GEHA Commercial |
$5,359.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,029.10
|
| Rate for Payer: Humana ChoiceCare |
$1,741.74
|
| Rate for Payer: Multiplan All |
$6,096.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,019.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,689.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,029.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,364.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,024.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,895.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,674.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,230.07
|
| Rate for Payer: Zelis Auto |
$2,679.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,349.50
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4 LEFT
|
Facility
|
OP
|
$7,552.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001816
|
|
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 SIZE 4 LEFT
|
Facility
|
IP
|
$7,552.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001816
|
|
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 4 MAKO
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001926
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.50 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,993.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Humana ChoiceCare |
$1,622.92
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,745.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,492.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,560.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,121.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4 MAKO
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001926
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.80 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,993.60
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,369.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4 RM/LL
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.80 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,993.60
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,369.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 4 RM/LL
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.50 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,993.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Humana ChoiceCare |
$1,622.92
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,745.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,492.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,560.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,121.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 5 LM/RL
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.80 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,993.60
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,369.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 5 LM/RL
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.50 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,993.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Humana ChoiceCare |
$1,622.92
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,745.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,492.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,560.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,121.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 5 RM/LL
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001929
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,496.80 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,993.60
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,369.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
|
|
IMPLT COMPONENT FEMORAL SIZE 5 RM/LL
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001929
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,560.50 |
| Max. Negotiated Rate |
$5,929.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cash Price |
$3,745.20
|
| Rate for Payer: Cigna Commercial |
$5,305.70
|
| Rate for Payer: First Health Commercial |
$5,617.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,617.80
|
| Rate for Payer: GEHA Commercial |
$4,993.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,617.80
|
| Rate for Payer: Humana ChoiceCare |
$1,622.92
|
| Rate for Payer: Multiplan All |
$5,680.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,745.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,369.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,617.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,929.90
|
| Rate for Payer: Three Rivers Provider Network All |
$4,681.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,492.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,560.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,805.06
|
| Rate for Payer: Zelis Auto |
$2,496.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,121.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 6
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.00 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,884.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,273.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
|
|
IMPLT COMPONENT FEMORAL SIZE 6
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,884.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Humana ChoiceCare |
$1,587.30
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,663.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,372.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,526.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,052.50
|
|
