|
IMPLT FEMORAL CEMENTED PRIMARY RT LARGE
|
Facility
|
OP
|
$12,209.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,052.25 |
| Max. Negotiated Rate |
$11,598.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cigna Commercial |
$10,377.65
|
| Rate for Payer: First Health Commercial |
$10,988.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,988.10
|
| Rate for Payer: GEHA Commercial |
$9,767.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,988.10
|
| Rate for Payer: Humana ChoiceCare |
$3,174.34
|
| Rate for Payer: Multiplan All |
$11,110.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,325.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,546.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,988.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,598.55
|
| Rate for Payer: Three Rivers Provider Network All |
$9,156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,743.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,052.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,354.37
|
| Rate for Payer: Zelis Auto |
$4,883.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,104.50
|
|
|
IMPLT FEMORAL CERAMIC HEAD
|
Facility
|
OP
|
$6,942.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,735.50 |
| Max. Negotiated Rate |
$6,594.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,165.20
|
| Rate for Payer: Cash Price |
$4,165.20
|
| Rate for Payer: Cash Price |
$4,165.20
|
| Rate for Payer: Cigna Commercial |
$5,900.70
|
| Rate for Payer: First Health Commercial |
$6,247.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,247.80
|
| Rate for Payer: GEHA Commercial |
$5,553.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,247.80
|
| Rate for Payer: Humana ChoiceCare |
$1,804.92
|
| Rate for Payer: Multiplan All |
$6,317.22
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,165.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,859.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,247.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,594.90
|
| Rate for Payer: Three Rivers Provider Network All |
$5,206.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,108.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,735.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,456.06
|
| Rate for Payer: Zelis Auto |
$2,776.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,471.00
|
|
|
IMPLT FEMORAL CERAMIC HEAD
|
Facility
|
IP
|
$6,942.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,776.80 |
| Max. Negotiated Rate |
$6,594.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,553.60
|
| Rate for Payer: Cash Price |
$4,165.20
|
| Rate for Payer: Cash Price |
$4,165.20
|
| Rate for Payer: Cigna Commercial |
$5,900.70
|
| Rate for Payer: First Health Commercial |
$6,247.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,247.80
|
| Rate for Payer: GEHA Commercial |
$4,859.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,247.80
|
| Rate for Payer: Multiplan All |
$6,317.22
|
| Rate for Payer: OMNI Networks Commercial |
$4,859.40
|
| Rate for Payer: One Health Plan PPO/POS |
$6,247.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,594.90
|
| Rate for Payer: Three Rivers Provider Network All |
$5,206.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,456.06
|
| Rate for Payer: Zelis Auto |
$2,776.80
|
|
|
IMPLT FEMORAL CERAMIC HEAD 032MM+1 12/14
|
Facility
|
OP
|
$15,855.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,963.75 |
| Max. Negotiated Rate |
$15,062.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,513.00
|
| Rate for Payer: Cash Price |
$9,513.00
|
| Rate for Payer: Cash Price |
$9,513.00
|
| Rate for Payer: Cigna Commercial |
$13,476.75
|
| Rate for Payer: First Health Commercial |
$14,269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,269.50
|
| Rate for Payer: GEHA Commercial |
$12,684.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,269.50
|
| Rate for Payer: Humana ChoiceCare |
$4,122.30
|
| Rate for Payer: Multiplan All |
$14,428.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$9,513.00
|
| Rate for Payer: OMNI Networks Commercial |
$11,098.50
|
| Rate for Payer: One Health Plan PPO/POS |
$14,269.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,062.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11,891.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$13,952.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,963.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14,745.15
|
| Rate for Payer: Zelis Auto |
$6,342.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,927.50
|
|
|
IMPLT FEMORAL CERAMIC HEAD 032MM+1 12/14
|
Facility
|
IP
|
$15,855.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,342.00 |
| Max. Negotiated Rate |
$15,062.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,684.00
|
| Rate for Payer: Cash Price |
$9,513.00
|
| Rate for Payer: Cash Price |
$9,513.00
|
| Rate for Payer: Cigna Commercial |
$13,476.75
|
| Rate for Payer: First Health Commercial |
$14,269.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,269.50
|
| Rate for Payer: GEHA Commercial |
$11,098.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,269.50
|
| Rate for Payer: Multiplan All |
$14,428.05
|
| Rate for Payer: OMNI Networks Commercial |
$11,098.50
|
| Rate for Payer: One Health Plan PPO/POS |
$14,269.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,062.25
|
| Rate for Payer: Three Rivers Provider Network All |
$11,891.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14,745.15
|
| Rate for Payer: Zelis Auto |
$6,342.00
|
|
|
IMPLT FEMORAL COMPONENT 1 RM/LL
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001556
|
|
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 FEMORAL COMPONENT 1 RM/LL
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001556
|
|
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 FEMORAL CONE SIZE MEDIUM
|
Facility
|
OP
|
$19,200.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,800.00 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11,520.00
|
| Rate for Payer: Cash Price |
$11,520.00
|
| Rate for Payer: Cash Price |
$11,520.00
|
| Rate for Payer: Cigna Commercial |
$16,320.00
|
| Rate for Payer: First Health Commercial |
$17,280.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17,280.00
|
| Rate for Payer: GEHA Commercial |
$15,360.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17,280.00
|
| Rate for Payer: Humana ChoiceCare |
$4,992.00
|
| Rate for Payer: Multiplan All |
$17,472.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$11,520.00
|
| Rate for Payer: OMNI Networks Commercial |
$13,440.00
|
| Rate for Payer: One Health Plan PPO/POS |
$17,280.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18,240.00
|
| Rate for Payer: Three Rivers Provider Network All |
$14,400.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16,896.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,800.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17,856.00
|
| Rate for Payer: Zelis Auto |
$7,680.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9,600.00
|
|
|
IMPLT FEMORAL CONE SIZE MEDIUM
|
Facility
|
IP
|
$19,200.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,680.00 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$15,360.00
|
| Rate for Payer: Cash Price |
$11,520.00
|
| Rate for Payer: Cash Price |
$11,520.00
|
| Rate for Payer: Cigna Commercial |
$16,320.00
|
| Rate for Payer: First Health Commercial |
$17,280.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$17,280.00
|
| Rate for Payer: GEHA Commercial |
$13,440.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$17,280.00
|
| Rate for Payer: Multiplan All |
$17,472.00
|
| Rate for Payer: OMNI Networks Commercial |
$13,440.00
|
| Rate for Payer: One Health Plan PPO/POS |
$17,280.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$18,240.00
|
| Rate for Payer: Three Rivers Provider Network All |
$14,400.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$17,856.00
|
| Rate for Payer: Zelis Auto |
$7,680.00
|
|
|
IMPLT FEMORAL CRUCIATE SIZE3 RIGHT
|
Facility
|
OP
|
$5,807.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.75 |
| Max. Negotiated Rate |
$5,516.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,484.20
|
| Rate for Payer: Cash Price |
$3,484.20
|
| Rate for Payer: Cash Price |
$3,484.20
|
| Rate for Payer: Cigna Commercial |
$4,935.95
|
| Rate for Payer: First Health Commercial |
$5,226.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,226.30
|
| Rate for Payer: GEHA Commercial |
$4,645.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,226.30
|
| Rate for Payer: Humana ChoiceCare |
$1,509.82
|
| Rate for Payer: Multiplan All |
$5,284.37
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,484.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,064.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,226.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,516.65
|
| Rate for Payer: Three Rivers Provider Network All |
$4,355.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,110.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,451.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,400.51
|
| Rate for Payer: Zelis Auto |
$2,322.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,903.50
|
|
|
IMPLT FEMORAL CRUCIATE SIZE3 RIGHT
|
Facility
|
IP
|
$5,807.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.80 |
| Max. Negotiated Rate |
$5,516.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,645.60
|
| Rate for Payer: Cash Price |
$3,484.20
|
| Rate for Payer: Cash Price |
$3,484.20
|
| Rate for Payer: Cigna Commercial |
$4,935.95
|
| Rate for Payer: First Health Commercial |
$5,226.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,226.30
|
| Rate for Payer: GEHA Commercial |
$4,064.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,226.30
|
| Rate for Payer: Multiplan All |
$5,284.37
|
| Rate for Payer: OMNI Networks Commercial |
$4,064.90
|
| Rate for Payer: One Health Plan PPO/POS |
$5,226.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,516.65
|
| Rate for Payer: Three Rivers Provider Network All |
$4,355.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,400.51
|
| Rate for Payer: Zelis Auto |
$2,322.80
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RIGHT 5MM
|
Facility
|
IP
|
$4,143.90
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,657.56 |
| Max. Negotiated Rate |
$3,936.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,315.12
|
| Rate for Payer: Cash Price |
$2,486.34
|
| Rate for Payer: Cash Price |
$2,486.34
|
| Rate for Payer: Cigna Commercial |
$3,522.32
|
| Rate for Payer: First Health Commercial |
$3,729.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,729.51
|
| Rate for Payer: GEHA Commercial |
$2,900.73
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,729.51
|
| Rate for Payer: Multiplan All |
$3,770.95
|
| Rate for Payer: OMNI Networks Commercial |
$2,900.73
|
| Rate for Payer: One Health Plan PPO/POS |
$3,729.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,936.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,107.93
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,853.83
|
| Rate for Payer: Zelis Auto |
$1,657.56
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RIGHT 5MM
|
Facility
|
OP
|
$4,143.90
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,035.97 |
| Max. Negotiated Rate |
$3,936.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,486.34
|
| Rate for Payer: Cash Price |
$2,486.34
|
| Rate for Payer: Cash Price |
$2,486.34
|
| Rate for Payer: Cigna Commercial |
$3,522.32
|
| Rate for Payer: First Health Commercial |
$3,729.51
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,729.51
|
| Rate for Payer: GEHA Commercial |
$3,315.12
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,729.51
|
| Rate for Payer: Humana ChoiceCare |
$1,077.41
|
| Rate for Payer: Multiplan All |
$3,770.95
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,486.34
|
| Rate for Payer: OMNI Networks Commercial |
$2,900.73
|
| Rate for Payer: One Health Plan PPO/POS |
$3,729.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,936.70
|
| Rate for Payer: Three Rivers Provider Network All |
$3,107.93
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,646.63
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,035.97
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,853.83
|
| Rate for Payer: Zelis Auto |
$1,657.56
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,071.95
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RIGHT 5MM
|
Facility
|
OP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,985.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Humana ChoiceCare |
$970.32
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,239.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,284.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$933.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,866.00
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RIGHT 5MM
|
Facility
|
IP
|
$3,732.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.80 |
| Max. Negotiated Rate |
$3,545.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,985.60
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cash Price |
$2,239.20
|
| Rate for Payer: Cigna Commercial |
$3,172.20
|
| Rate for Payer: First Health Commercial |
$3,358.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,358.80
|
| Rate for Payer: GEHA Commercial |
$2,612.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,358.80
|
| Rate for Payer: Multiplan All |
$3,396.12
|
| Rate for Payer: OMNI Networks Commercial |
$2,612.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,358.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,545.40
|
| Rate for Payer: Three Rivers Provider Network All |
$2,799.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,470.76
|
| Rate for Payer: Zelis Auto |
$1,492.80
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RT
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,401.20
|
| Rate for Payer: Cash Price |
$2,401.20
|
| Rate for Payer: Cash Price |
$2,401.20
|
| Rate for Payer: Cigna Commercial |
$3,401.70
|
| Rate for Payer: First Health Commercial |
$3,601.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,601.80
|
| Rate for Payer: GEHA Commercial |
$3,201.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,601.80
|
| Rate for Payer: Humana ChoiceCare |
$1,040.52
|
| Rate for Payer: Multiplan All |
$3,641.82
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,401.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,801.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,601.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,801.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,001.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,521.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,000.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,721.86
|
| Rate for Payer: Zelis Auto |
$1,600.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,001.00
|
|
|
IMPLT FEMORAL DISTAL AUGMENT RT
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007029
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,600.80 |
| Max. Negotiated Rate |
$3,801.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,201.60
|
| Rate for Payer: Cash Price |
$2,401.20
|
| Rate for Payer: Cash Price |
$2,401.20
|
| Rate for Payer: Cigna Commercial |
$3,401.70
|
| Rate for Payer: First Health Commercial |
$3,601.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,601.80
|
| Rate for Payer: GEHA Commercial |
$2,801.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,601.80
|
| Rate for Payer: Multiplan All |
$3,641.82
|
| Rate for Payer: OMNI Networks Commercial |
$2,801.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,601.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,801.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,001.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,721.86
|
| Rate for Payer: Zelis Auto |
$1,600.80
|
|
|
IMPLT FEMORAL HEAD 32MM +12MM
|
Facility
|
IP
|
$2,661.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.72 |
| Max. Negotiated Rate |
$2,528.71 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,129.44
|
| Rate for Payer: Cash Price |
$1,597.08
|
| Rate for Payer: Cash Price |
$1,597.08
|
| Rate for Payer: Cigna Commercial |
$2,262.53
|
| Rate for Payer: First Health Commercial |
$2,395.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,395.62
|
| Rate for Payer: GEHA Commercial |
$1,863.26
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,395.62
|
| Rate for Payer: Multiplan All |
$2,422.24
|
| Rate for Payer: OMNI Networks Commercial |
$1,863.26
|
| Rate for Payer: One Health Plan PPO/POS |
$2,395.62
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,528.71
|
| Rate for Payer: Three Rivers Provider Network All |
$1,996.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,475.47
|
| Rate for Payer: Zelis Auto |
$1,064.72
|
|
|
IMPLT FEMORAL HEAD 32MM +12MM
|
Facility
|
OP
|
$2,661.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$665.45 |
| Max. Negotiated Rate |
$2,528.71 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,597.08
|
| Rate for Payer: Cash Price |
$1,597.08
|
| Rate for Payer: Cash Price |
$1,597.08
|
| Rate for Payer: Cigna Commercial |
$2,262.53
|
| Rate for Payer: First Health Commercial |
$2,395.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,395.62
|
| Rate for Payer: GEHA Commercial |
$2,129.44
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,395.62
|
| Rate for Payer: Humana ChoiceCare |
$692.07
|
| Rate for Payer: Multiplan All |
$2,422.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,597.08
|
| Rate for Payer: OMNI Networks Commercial |
$1,863.26
|
| Rate for Payer: One Health Plan PPO/POS |
$2,395.62
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,528.71
|
| Rate for Payer: Three Rivers Provider Network All |
$1,996.35
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,342.38
|
| Rate for Payer: United Healthcare Managed Medicaid |
$665.45
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,475.47
|
| Rate for Payer: Zelis Auto |
$1,064.72
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,330.90
|
|
|
IMPLT FEMORAL HEAD LFIT V40
|
Facility
|
OP
|
$2,194.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003428
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$548.50 |
| Max. Negotiated Rate |
$2,084.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,316.40
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cigna Commercial |
$1,864.90
|
| Rate for Payer: First Health Commercial |
$1,974.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,974.60
|
| Rate for Payer: GEHA Commercial |
$1,755.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,974.60
|
| Rate for Payer: Humana ChoiceCare |
$570.44
|
| Rate for Payer: Multiplan All |
$1,996.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,316.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,535.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,974.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,084.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,645.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,930.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$548.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,040.42
|
| Rate for Payer: Zelis Auto |
$877.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,097.00
|
|
|
IMPLT FEMORAL HEAD LFIT V40
|
Facility
|
IP
|
$2,194.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003428
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$877.60 |
| Max. Negotiated Rate |
$2,084.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,755.20
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cash Price |
$1,316.40
|
| Rate for Payer: Cigna Commercial |
$1,864.90
|
| Rate for Payer: First Health Commercial |
$1,974.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,974.60
|
| Rate for Payer: GEHA Commercial |
$1,535.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,974.60
|
| Rate for Payer: Multiplan All |
$1,996.54
|
| Rate for Payer: OMNI Networks Commercial |
$1,535.80
|
| Rate for Payer: One Health Plan PPO/POS |
$1,974.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,084.30
|
| Rate for Payer: Three Rivers Provider Network All |
$1,645.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,040.42
|
| Rate for Payer: Zelis Auto |
$877.60
|
|
|
IMPLT FEMORAL KNEE CEMENT MOLD 60MM
|
Facility
|
IP
|
$9,379.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,751.60 |
| Max. Negotiated Rate |
$8,910.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,503.20
|
| Rate for Payer: Cash Price |
$5,627.40
|
| Rate for Payer: Cash Price |
$5,627.40
|
| Rate for Payer: Cigna Commercial |
$7,972.15
|
| Rate for Payer: First Health Commercial |
$8,441.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,441.10
|
| Rate for Payer: GEHA Commercial |
$6,565.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,441.10
|
| Rate for Payer: Multiplan All |
$8,534.89
|
| Rate for Payer: OMNI Networks Commercial |
$6,565.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8,441.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,910.05
|
| Rate for Payer: Three Rivers Provider Network All |
$7,034.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,722.47
|
| Rate for Payer: Zelis Auto |
$3,751.60
|
|
|
IMPLT FEMORAL KNEE CEMENT MOLD 60MM
|
Facility
|
OP
|
$9,379.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,344.75 |
| Max. Negotiated Rate |
$8,910.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,627.40
|
| Rate for Payer: Cash Price |
$5,627.40
|
| Rate for Payer: Cash Price |
$5,627.40
|
| Rate for Payer: Cigna Commercial |
$7,972.15
|
| Rate for Payer: First Health Commercial |
$8,441.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,441.10
|
| Rate for Payer: GEHA Commercial |
$7,503.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,441.10
|
| Rate for Payer: Humana ChoiceCare |
$2,438.54
|
| Rate for Payer: Multiplan All |
$8,534.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,627.40
|
| Rate for Payer: OMNI Networks Commercial |
$6,565.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8,441.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,910.05
|
| Rate for Payer: Three Rivers Provider Network All |
$7,034.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,253.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,344.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,722.47
|
| Rate for Payer: Zelis Auto |
$3,751.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,689.50
|
|
|
IMPLT FEMORAL LARGE LEFT
|
Facility
|
IP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,666.00 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,332.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$8,165.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
|
|
IMPLT FEMORAL LARGE LEFT
|
Facility
|
OP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,916.25 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$9,332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Humana ChoiceCare |
$3,032.90
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,999.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,265.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,916.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,832.50
|
|
