|
IMPLT COMPONENT FEMORAL SZ5
|
Facility
|
OP
|
$883.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001945
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$220.75 |
| Max. Negotiated Rate |
$838.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$529.80
|
| Rate for Payer: Cash Price |
$529.80
|
| Rate for Payer: Cash Price |
$529.80
|
| Rate for Payer: Cigna Commercial |
$750.55
|
| Rate for Payer: First Health Commercial |
$794.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$794.70
|
| Rate for Payer: GEHA Commercial |
$706.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$794.70
|
| Rate for Payer: Humana ChoiceCare |
$229.58
|
| Rate for Payer: Multiplan All |
$803.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$529.80
|
| Rate for Payer: OMNI Networks Commercial |
$618.10
|
| Rate for Payer: One Health Plan PPO/POS |
$794.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$838.85
|
| Rate for Payer: Three Rivers Provider Network All |
$662.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$777.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$220.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$821.19
|
| Rate for Payer: Zelis Auto |
$353.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$441.50
|
|
|
IMPLT COMPONENT FEMORAL TRIATHLON #3
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001834
|
|
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 TRIATHLON #3
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001834
|
|
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 HEAD 46MM OD
|
Facility
|
IP
|
$3,045.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,436.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,131.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
|
|
IMPLT COMPONENT HEAD 46MM OD
|
Facility
|
OP
|
$3,045.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$761.25 |
| Max. Negotiated Rate |
$2,892.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: Cigna Commercial |
$2,588.25
|
| Rate for Payer: First Health Commercial |
$2,740.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,740.50
|
| Rate for Payer: GEHA Commercial |
$2,436.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,740.50
|
| Rate for Payer: Humana ChoiceCare |
$791.70
|
| Rate for Payer: Multiplan All |
$2,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,827.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,131.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,740.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,892.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,283.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,679.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$761.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,831.85
|
| Rate for Payer: Zelis Auto |
$1,218.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,522.50
|
|
|
IMPLT COMPONENT HEAD BIPOLAR 46X26MM
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.25 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,780.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Humana ChoiceCare |
$578.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,335.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,958.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$556.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,112.50
|
|
|
IMPLT COMPONENT HEAD BIPOLAR 46X26MM
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.00 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,780.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,557.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
|
|
IMPLT COMPONENT HEAD BIPOLAR 50MM
|
Facility
|
IP
|
$2,817.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.80 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,253.60
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$1,971.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
|
|
IMPLT COMPONENT HEAD BIPOLAR 50MM
|
Facility
|
OP
|
$2,817.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$704.25 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$2,253.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Humana ChoiceCare |
$732.42
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,690.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,478.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$704.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,408.50
|
|
|
IMPLT COMPONENT HEAD ENDOPROSTHESIS 45MM
|
Facility
|
IP
|
$2,817.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.80 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,253.60
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$1,971.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
|
|
IMPLT COMPONENT HEAD ENDOPROSTHESIS 45MM
|
Facility
|
OP
|
$2,817.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$704.25 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$2,253.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Humana ChoiceCare |
$732.42
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,690.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,478.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$704.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,408.50
|
|
|
IMPLT COMPONENT HEAD MODULAR 28MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$951.50 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$3,044.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Humana ChoiceCare |
$989.56
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,283.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,349.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$951.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,903.00
|
|
|
IMPLT COMPONENT HEAD MODULAR 28MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001844
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.40 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,044.80
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$2,664.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
|
|
IMPLT COMPONENT HEAD UNI OD41MM
|
Facility
|
OP
|
$1,578.32
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$394.58 |
| Max. Negotiated Rate |
$1,499.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cigna Commercial |
$1,341.57
|
| Rate for Payer: First Health Commercial |
$1,420.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,420.49
|
| Rate for Payer: GEHA Commercial |
$1,262.66
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,420.49
|
| Rate for Payer: Humana ChoiceCare |
$410.36
|
| Rate for Payer: Multiplan All |
$1,436.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$946.99
|
| Rate for Payer: OMNI Networks Commercial |
$1,104.82
|
| Rate for Payer: One Health Plan PPO/POS |
$1,420.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,499.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,183.74
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,388.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$394.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,467.84
|
| Rate for Payer: Zelis Auto |
$631.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$789.16
|
|
|
IMPLT COMPONENT HEAD UNI OD41MM
|
Facility
|
IP
|
$1,578.32
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$631.33 |
| Max. Negotiated Rate |
$1,499.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,262.66
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cigna Commercial |
$1,341.57
|
| Rate for Payer: First Health Commercial |
$1,420.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,420.49
|
| Rate for Payer: GEHA Commercial |
$1,104.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,420.49
|
| Rate for Payer: Multiplan All |
$1,436.27
|
| Rate for Payer: OMNI Networks Commercial |
$1,104.82
|
| Rate for Payer: One Health Plan PPO/POS |
$1,420.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,499.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,183.74
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,467.84
|
| Rate for Payer: Zelis Auto |
$631.33
|
|
|
IMPLT COMPONENT HEAD UNI OD44MM
|
Facility
|
OP
|
$1,578.32
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001817
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$394.58 |
| Max. Negotiated Rate |
$1,499.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cigna Commercial |
$1,341.57
|
| Rate for Payer: First Health Commercial |
$1,420.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,420.49
|
| Rate for Payer: GEHA Commercial |
$1,262.66
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,420.49
|
| Rate for Payer: Humana ChoiceCare |
$410.36
|
| Rate for Payer: Multiplan All |
$1,436.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$946.99
|
| Rate for Payer: OMNI Networks Commercial |
$1,104.82
|
| Rate for Payer: One Health Plan PPO/POS |
$1,420.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,499.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,183.74
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,388.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$394.58
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,467.84
|
| Rate for Payer: Zelis Auto |
$631.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$789.16
|
|
|
IMPLT COMPONENT HEAD UNI OD44MM
|
Facility
|
IP
|
$1,578.32
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001817
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$631.33 |
| Max. Negotiated Rate |
$1,499.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,262.66
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cash Price |
$946.99
|
| Rate for Payer: Cigna Commercial |
$1,341.57
|
| Rate for Payer: First Health Commercial |
$1,420.49
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,420.49
|
| Rate for Payer: GEHA Commercial |
$1,104.82
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,420.49
|
| Rate for Payer: Multiplan All |
$1,436.27
|
| Rate for Payer: OMNI Networks Commercial |
$1,104.82
|
| Rate for Payer: One Health Plan PPO/POS |
$1,420.49
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,499.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,183.74
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,467.84
|
| Rate for Payer: Zelis Auto |
$631.33
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL 56MM
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.00 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,780.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,557.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL 56MM
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.25 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,780.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Humana ChoiceCare |
$578.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,335.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,958.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$556.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,112.50
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL 58MM 26MM
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.00 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,780.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,557.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL 58MM 26MM
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.25 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,780.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Humana ChoiceCare |
$578.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,335.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,958.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$556.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,112.50
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL BIPOLAR
|
Facility
|
OP
|
$2,817.00
|
|
| Hospital Charge Code |
7006375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$704.25 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$2,253.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Humana ChoiceCare |
$732.42
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,690.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,478.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$704.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,408.50
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL BIPOLAR
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.25 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,780.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Humana ChoiceCare |
$578.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,335.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,958.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$556.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,112.50
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL BIPOLAR
|
Facility
|
IP
|
$2,817.00
|
|
| Hospital Charge Code |
7006375
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.80 |
| Max. Negotiated Rate |
$2,676.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,253.60
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cash Price |
$1,690.20
|
| Rate for Payer: Cigna Commercial |
$2,394.45
|
| Rate for Payer: First Health Commercial |
$2,535.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,535.30
|
| Rate for Payer: GEHA Commercial |
$1,971.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,535.30
|
| Rate for Payer: Multiplan All |
$2,563.47
|
| Rate for Payer: OMNI Networks Commercial |
$1,971.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,535.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,676.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,112.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,619.81
|
| Rate for Payer: Zelis Auto |
$1,126.80
|
|
|
IMPLT COMPONENT HEAD UNIVERSAL BIPOLAR
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.00 |
| Max. Negotiated Rate |
$2,113.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,780.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$1,891.25
|
| Rate for Payer: First Health Commercial |
$2,002.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,002.50
|
| Rate for Payer: GEHA Commercial |
$1,557.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,002.50
|
| Rate for Payer: Multiplan All |
$2,024.75
|
| Rate for Payer: OMNI Networks Commercial |
$1,557.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,002.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,113.75
|
| Rate for Payer: Three Rivers Provider Network All |
$1,668.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,069.25
|
| Rate for Payer: Zelis Auto |
$890.00
|
|
