|
IMPLT COMPONENT MODULAR HEAD 32MM
|
Facility
|
IP
|
$3,745.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.00 |
| Max. Negotiated Rate |
$3,557.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,996.00
|
| Rate for Payer: Cash Price |
$2,247.00
|
| Rate for Payer: Cash Price |
$2,247.00
|
| Rate for Payer: Cigna Commercial |
$3,183.25
|
| Rate for Payer: First Health Commercial |
$3,370.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,370.50
|
| Rate for Payer: GEHA Commercial |
$2,621.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,370.50
|
| Rate for Payer: Multiplan All |
$3,407.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,621.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,370.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,557.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,808.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,482.85
|
| Rate for Payer: Zelis Auto |
$1,498.00
|
|
|
IMPLT COMPONENT MODULAR HEAD 32MM
|
Facility
|
OP
|
$3,745.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$936.25 |
| Max. Negotiated Rate |
$3,557.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,247.00
|
| Rate for Payer: Cash Price |
$2,247.00
|
| Rate for Payer: Cash Price |
$2,247.00
|
| Rate for Payer: Cigna Commercial |
$3,183.25
|
| Rate for Payer: First Health Commercial |
$3,370.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,370.50
|
| Rate for Payer: GEHA Commercial |
$2,996.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,370.50
|
| Rate for Payer: Humana ChoiceCare |
$973.70
|
| Rate for Payer: Multiplan All |
$3,407.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,247.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,621.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,370.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,557.75
|
| Rate for Payer: Three Rivers Provider Network All |
$2,808.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,295.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$936.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,482.85
|
| Rate for Payer: Zelis Auto |
$1,498.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,872.50
|
|
|
IMPLT COMPONENT PATELLA 32MM
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.00 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$2,070.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Humana ChoiceCare |
$672.88
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,552.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,277.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$647.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,294.00
|
|
|
IMPLT COMPONENT PATELLA 32MM
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,035.20 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,070.40
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$1,811.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
|
|
IMPLT COMPONENT PATELLA SIZE 38MM
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.00 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$2,070.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Humana ChoiceCare |
$672.88
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,552.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,277.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$647.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,294.00
|
|
|
IMPLT COMPONENT PATELLA SIZE 38MM
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,035.20 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,070.40
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$1,811.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
|
|
IMPLT COMPONENT PATELLA SZ 35MM
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,035.20 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,070.40
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$1,811.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
|
|
IMPLT COMPONENT PATELLA SZ 35MM
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006549
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.00 |
| Max. Negotiated Rate |
$2,458.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cigna Commercial |
$2,199.80
|
| Rate for Payer: First Health Commercial |
$2,329.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,329.20
|
| Rate for Payer: GEHA Commercial |
$2,070.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,329.20
|
| Rate for Payer: Humana ChoiceCare |
$672.88
|
| Rate for Payer: Multiplan All |
$2,355.08
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,552.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,811.60
|
| Rate for Payer: One Health Plan PPO/POS |
$2,329.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,458.60
|
| Rate for Payer: Three Rivers Provider Network All |
$1,941.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,277.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$647.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,406.84
|
| Rate for Payer: Zelis Auto |
$1,035.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,294.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL #3 MAKO
|
Facility
|
OP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.00 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$7,916.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Humana ChoiceCare |
$2,572.96
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,937.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,708.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,474.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,948.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL #3 MAKO
|
Facility
|
IP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,958.40 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,916.80
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$6,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
|
|
IMPLT COMPONENT PATELLOFEMORAL #4 RIGHT
|
Facility
|
OP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.00 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$7,916.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Humana ChoiceCare |
$2,572.96
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,937.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,708.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,474.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,948.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL #4 RIGHT
|
Facility
|
IP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,958.40 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,916.80
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$6,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
|
|
IMPLT COMPONENT PATELLOFEMORAL LEFT #5
|
Facility
|
IP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006121
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,958.40 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,916.80
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$6,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
|
|
IMPLT COMPONENT PATELLOFEMORAL LEFT #5
|
Facility
|
OP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006121
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.00 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$7,916.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Humana ChoiceCare |
$2,572.96
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,937.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,708.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,474.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,948.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 3
|
Facility
|
OP
|
$9,287.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002488
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,321.75 |
| Max. Negotiated Rate |
$8,822.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cigna Commercial |
$7,893.95
|
| Rate for Payer: First Health Commercial |
$8,358.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,358.30
|
| Rate for Payer: GEHA Commercial |
$7,429.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,358.30
|
| Rate for Payer: Humana ChoiceCare |
$2,414.62
|
| Rate for Payer: Multiplan All |
$8,451.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,572.20
|
| Rate for Payer: OMNI Networks Commercial |
$6,500.90
|
| Rate for Payer: One Health Plan PPO/POS |
$8,358.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,822.65
|
| Rate for Payer: Three Rivers Provider Network All |
$6,965.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,172.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,321.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,636.91
|
| Rate for Payer: Zelis Auto |
$3,714.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,643.50
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 3
|
Facility
|
IP
|
$9,287.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002488
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,714.80 |
| Max. Negotiated Rate |
$8,822.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,429.60
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cigna Commercial |
$7,893.95
|
| Rate for Payer: First Health Commercial |
$8,358.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,358.30
|
| Rate for Payer: GEHA Commercial |
$6,500.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,358.30
|
| Rate for Payer: Multiplan All |
$8,451.17
|
| Rate for Payer: OMNI Networks Commercial |
$6,500.90
|
| Rate for Payer: One Health Plan PPO/POS |
$8,358.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,822.65
|
| Rate for Payer: Three Rivers Provider Network All |
$6,965.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,636.91
|
| Rate for Payer: Zelis Auto |
$3,714.80
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 4
|
Facility
|
IP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,958.40 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,916.80
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$6,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 4
|
Facility
|
OP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002512
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.00 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$7,916.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Humana ChoiceCare |
$2,572.96
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,937.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,708.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,474.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,948.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 5
|
Facility
|
IP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,958.40 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,916.80
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$6,927.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 5
|
Facility
|
OP
|
$9,896.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.00 |
| Max. Negotiated Rate |
$9,401.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cash Price |
$5,937.60
|
| Rate for Payer: Cigna Commercial |
$8,411.60
|
| Rate for Payer: First Health Commercial |
$8,906.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,906.40
|
| Rate for Payer: GEHA Commercial |
$7,916.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,906.40
|
| Rate for Payer: Humana ChoiceCare |
$2,572.96
|
| Rate for Payer: Multiplan All |
$9,005.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,937.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,927.20
|
| Rate for Payer: One Health Plan PPO/POS |
$8,906.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,401.20
|
| Rate for Payer: Three Rivers Provider Network All |
$7,422.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,708.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,474.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,203.28
|
| Rate for Payer: Zelis Auto |
$3,958.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,948.00
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 6
|
Facility
|
IP
|
$9,287.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003169
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,714.80 |
| Max. Negotiated Rate |
$8,822.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,429.60
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cigna Commercial |
$7,893.95
|
| Rate for Payer: First Health Commercial |
$8,358.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,358.30
|
| Rate for Payer: GEHA Commercial |
$6,500.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,358.30
|
| Rate for Payer: Multiplan All |
$8,451.17
|
| Rate for Payer: OMNI Networks Commercial |
$6,500.90
|
| Rate for Payer: One Health Plan PPO/POS |
$8,358.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,822.65
|
| Rate for Payer: Three Rivers Provider Network All |
$6,965.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,636.91
|
| Rate for Payer: Zelis Auto |
$3,714.80
|
|
|
IMPLT COMPONENT PATELLOFEMORAL SIZE 6
|
Facility
|
OP
|
$9,287.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003169
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,321.75 |
| Max. Negotiated Rate |
$8,822.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cash Price |
$5,572.20
|
| Rate for Payer: Cigna Commercial |
$7,893.95
|
| Rate for Payer: First Health Commercial |
$8,358.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,358.30
|
| Rate for Payer: GEHA Commercial |
$7,429.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,358.30
|
| Rate for Payer: Humana ChoiceCare |
$2,414.62
|
| Rate for Payer: Multiplan All |
$8,451.17
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,572.20
|
| Rate for Payer: OMNI Networks Commercial |
$6,500.90
|
| Rate for Payer: One Health Plan PPO/POS |
$8,358.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,822.65
|
| Rate for Payer: Three Rivers Provider Network All |
$6,965.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,172.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,321.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,636.91
|
| Rate for Payer: Zelis Auto |
$3,714.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,643.50
|
|
|
IMPLT COMPONENT POST STRAIGHT
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$316.80 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.60
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cigna Commercial |
$673.20
|
| Rate for Payer: First Health Commercial |
$712.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$712.80
|
| Rate for Payer: GEHA Commercial |
$554.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$712.80
|
| Rate for Payer: Multiplan All |
$720.72
|
| Rate for Payer: OMNI Networks Commercial |
$554.40
|
| Rate for Payer: One Health Plan PPO/POS |
$712.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$752.40
|
| Rate for Payer: Three Rivers Provider Network All |
$594.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$736.56
|
| Rate for Payer: Zelis Auto |
$316.80
|
|
|
IMPLT COMPONENT POST STRAIGHT
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$475.20
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cash Price |
$475.20
|
| Rate for Payer: Cigna Commercial |
$673.20
|
| Rate for Payer: First Health Commercial |
$712.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$712.80
|
| Rate for Payer: GEHA Commercial |
$633.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$712.80
|
| Rate for Payer: Humana ChoiceCare |
$205.92
|
| Rate for Payer: Multiplan All |
$720.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$475.20
|
| Rate for Payer: OMNI Networks Commercial |
$554.40
|
| Rate for Payer: One Health Plan PPO/POS |
$712.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$752.40
|
| Rate for Payer: Three Rivers Provider Network All |
$594.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$696.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$198.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$736.56
|
| Rate for Payer: Zelis Auto |
$316.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$396.00
|
|
|
IMPLT COMPONENT ROTATING TIBIAL
|
Facility
|
OP
|
$8,263.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.75 |
| Max. Negotiated Rate |
$7,849.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,957.80
|
| Rate for Payer: Cash Price |
$4,957.80
|
| Rate for Payer: Cash Price |
$4,957.80
|
| Rate for Payer: Cigna Commercial |
$7,023.55
|
| Rate for Payer: First Health Commercial |
$7,436.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,436.70
|
| Rate for Payer: GEHA Commercial |
$6,610.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,436.70
|
| Rate for Payer: Humana ChoiceCare |
$2,148.38
|
| Rate for Payer: Multiplan All |
$7,519.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,957.80
|
| Rate for Payer: OMNI Networks Commercial |
$5,784.10
|
| Rate for Payer: One Health Plan PPO/POS |
$7,436.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,849.85
|
| Rate for Payer: Three Rivers Provider Network All |
$6,197.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,271.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,065.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,684.59
|
| Rate for Payer: Zelis Auto |
$3,305.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,131.50
|
|
