|
IMPLT FLOSEAL 5ML
|
Facility
|
OP
|
$1,064.00
|
|
|
Service Code
|
CPT C1760
|
| Hospital Charge Code |
7001698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.00 |
| Max. Negotiated Rate |
$1,010.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$638.40
|
| Rate for Payer: Cash Price |
$638.40
|
| Rate for Payer: Cash Price |
$638.40
|
| Rate for Payer: Cigna Commercial |
$904.40
|
| Rate for Payer: First Health Commercial |
$957.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$957.60
|
| Rate for Payer: GEHA Commercial |
$851.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$957.60
|
| Rate for Payer: Humana ChoiceCare |
$276.64
|
| Rate for Payer: Multiplan All |
$968.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$638.40
|
| Rate for Payer: OMNI Networks Commercial |
$744.80
|
| Rate for Payer: One Health Plan PPO/POS |
$957.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,010.80
|
| Rate for Payer: Three Rivers Provider Network All |
$798.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$936.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$266.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$989.52
|
| Rate for Payer: Zelis Auto |
$425.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$532.00
|
|
|
IMPLT GEL DBM .5CCX2
|
Facility
|
IP
|
$2,323.00
|
|
|
Service Code
|
CPT C9359
|
| Hospital Charge Code |
7002954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$929.20 |
| Max. Negotiated Rate |
$2,206.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,858.40
|
| Rate for Payer: Cash Price |
$1,393.80
|
| Rate for Payer: Cash Price |
$1,393.80
|
| Rate for Payer: Cigna Commercial |
$1,974.55
|
| Rate for Payer: First Health Commercial |
$2,090.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,090.70
|
| Rate for Payer: GEHA Commercial |
$1,626.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,090.70
|
| Rate for Payer: Multiplan All |
$2,113.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,626.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,090.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,206.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,742.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,160.39
|
| Rate for Payer: Zelis Auto |
$929.20
|
|
|
IMPLT GEL DBM .5CCX2
|
Facility
|
OP
|
$2,323.00
|
|
|
Service Code
|
CPT C9359
|
| Hospital Charge Code |
7002954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.75 |
| Max. Negotiated Rate |
$2,206.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,393.80
|
| Rate for Payer: Cash Price |
$1,393.80
|
| Rate for Payer: Cash Price |
$1,393.80
|
| Rate for Payer: Cigna Commercial |
$1,974.55
|
| Rate for Payer: First Health Commercial |
$2,090.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,090.70
|
| Rate for Payer: GEHA Commercial |
$1,858.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,090.70
|
| Rate for Payer: Humana ChoiceCare |
$603.98
|
| Rate for Payer: Multiplan All |
$2,113.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,393.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,626.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,090.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,206.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,742.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,044.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$580.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,160.39
|
| Rate for Payer: Zelis Auto |
$929.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,161.50
|
|
|
IMPLT GLENOID PRESSURING SELF SIZE 52
|
Facility
|
IP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001991
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,230.00 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,460.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$5,652.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
|
|
IMPLT GLENOID PRESSURING SELF SIZE 52
|
Facility
|
OP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001991
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,018.75 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$6,460.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Humana ChoiceCare |
$2,099.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,845.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,106.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,018.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,037.50
|
|
|
IMPLT GLENOID PRESSURIZING SELF 40 SIZE
|
Facility
|
OP
|
$14,114.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,528.50 |
| Max. Negotiated Rate |
$13,408.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,468.40
|
| Rate for Payer: Cash Price |
$8,468.40
|
| Rate for Payer: Cash Price |
$8,468.40
|
| Rate for Payer: Cigna Commercial |
$11,996.90
|
| Rate for Payer: First Health Commercial |
$12,702.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,702.60
|
| Rate for Payer: GEHA Commercial |
$11,291.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,702.60
|
| Rate for Payer: Humana ChoiceCare |
$3,669.64
|
| Rate for Payer: Multiplan All |
$12,843.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8,468.40
|
| Rate for Payer: OMNI Networks Commercial |
$9,879.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12,702.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,408.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10,585.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12,420.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,528.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,126.02
|
| Rate for Payer: Zelis Auto |
$5,645.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7,057.00
|
|
|
IMPLT GLENOID PRESSURIZING SELF 40 SIZE
|
Facility
|
IP
|
$14,114.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002704
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,645.60 |
| Max. Negotiated Rate |
$13,408.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$11,291.20
|
| Rate for Payer: Cash Price |
$8,468.40
|
| Rate for Payer: Cash Price |
$8,468.40
|
| Rate for Payer: Cigna Commercial |
$11,996.90
|
| Rate for Payer: First Health Commercial |
$12,702.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12,702.60
|
| Rate for Payer: GEHA Commercial |
$9,879.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12,702.60
|
| Rate for Payer: Multiplan All |
$12,843.74
|
| Rate for Payer: OMNI Networks Commercial |
$9,879.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12,702.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13,408.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10,585.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13,126.02
|
| Rate for Payer: Zelis Auto |
$5,645.60
|
|
|
IMPLT GLENOID PRESSURIZING SELF 44 SIZE
|
Facility
|
OP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,018.75 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$6,460.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Humana ChoiceCare |
$2,099.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,845.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,106.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,018.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,037.50
|
|
|
IMPLT GLENOID PRESSURIZING SELF 44 SIZE
|
Facility
|
IP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,230.00 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,460.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$5,652.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
|
|
IMPLT GLENOID PRESSURIZING SELF 48 SIZE
|
Facility
|
IP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002497
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,204.47 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: First Health Workers Compensation |
$3,117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$5,652.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2,204.47
|
|
|
IMPLT GLENOID PRESSURIZING SELF 48 SIZE
|
Facility
|
OP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002497
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,018.75 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: First Health Workers Compensation |
$3,117.76
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$6,460.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Humana ChoiceCare |
$2,099.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,845.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,106.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,018.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,037.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2,204.47
|
|
|
IMPLT GLENOID SELF PRESSURING SIZE44
|
Facility
|
IP
|
$11,294.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,517.60 |
| Max. Negotiated Rate |
$10,729.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,035.20
|
| Rate for Payer: Cash Price |
$6,776.40
|
| Rate for Payer: Cash Price |
$6,776.40
|
| Rate for Payer: Cigna Commercial |
$9,599.90
|
| Rate for Payer: First Health Commercial |
$10,164.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,164.60
|
| Rate for Payer: GEHA Commercial |
$7,905.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,164.60
|
| Rate for Payer: Multiplan All |
$10,277.54
|
| Rate for Payer: OMNI Networks Commercial |
$7,905.80
|
| Rate for Payer: One Health Plan PPO/POS |
$10,164.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,729.30
|
| Rate for Payer: Three Rivers Provider Network All |
$8,470.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,503.42
|
| Rate for Payer: Zelis Auto |
$4,517.60
|
|
|
IMPLT GLENOID SELF PRESSURING SIZE44
|
Facility
|
OP
|
$11,294.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001840
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,823.50 |
| Max. Negotiated Rate |
$10,729.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,776.40
|
| Rate for Payer: Cash Price |
$6,776.40
|
| Rate for Payer: Cash Price |
$6,776.40
|
| Rate for Payer: Cigna Commercial |
$9,599.90
|
| Rate for Payer: First Health Commercial |
$10,164.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,164.60
|
| Rate for Payer: GEHA Commercial |
$9,035.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,164.60
|
| Rate for Payer: Humana ChoiceCare |
$2,936.44
|
| Rate for Payer: Multiplan All |
$10,277.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,776.40
|
| Rate for Payer: OMNI Networks Commercial |
$7,905.80
|
| Rate for Payer: One Health Plan PPO/POS |
$10,164.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,729.30
|
| Rate for Payer: Three Rivers Provider Network All |
$8,470.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9,938.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,823.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,503.42
|
| Rate for Payer: Zelis Auto |
$4,517.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,647.00
|
|
|
IMPLT GLENOID SIZE 40 SELF PRESS
|
Facility
|
OP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,018.75 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$6,460.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Humana ChoiceCare |
$2,099.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,845.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,106.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,018.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,037.50
|
|
|
IMPLT GLENOID SIZE 40 SELF PRESS
|
Facility
|
IP
|
$8,075.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,230.00 |
| Max. Negotiated Rate |
$7,671.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,460.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cash Price |
$4,845.00
|
| Rate for Payer: Cigna Commercial |
$6,863.75
|
| Rate for Payer: First Health Commercial |
$7,267.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,267.50
|
| Rate for Payer: GEHA Commercial |
$5,652.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,267.50
|
| Rate for Payer: Multiplan All |
$7,348.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,652.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,267.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,671.25
|
| Rate for Payer: Three Rivers Provider Network All |
$6,056.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,509.75
|
| Rate for Payer: Zelis Auto |
$3,230.00
|
|
|
IMPLT GLENOID SMALL COFIELD2 POLY
|
Facility
|
OP
|
$5,078.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001841
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,269.50 |
| Max. Negotiated Rate |
$4,824.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,046.80
|
| Rate for Payer: Cash Price |
$3,046.80
|
| Rate for Payer: Cash Price |
$3,046.80
|
| Rate for Payer: Cigna Commercial |
$4,316.30
|
| Rate for Payer: First Health Commercial |
$4,570.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,570.20
|
| Rate for Payer: GEHA Commercial |
$4,062.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,570.20
|
| Rate for Payer: Humana ChoiceCare |
$1,320.28
|
| Rate for Payer: Multiplan All |
$4,620.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,046.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,554.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,570.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,824.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,808.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,468.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,269.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,722.54
|
| Rate for Payer: Zelis Auto |
$2,031.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,539.00
|
|
|
IMPLT GLENOID SMALL COFIELD2 POLY
|
Facility
|
IP
|
$5,078.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001841
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,031.20 |
| Max. Negotiated Rate |
$4,824.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,062.40
|
| Rate for Payer: Cash Price |
$3,046.80
|
| Rate for Payer: Cash Price |
$3,046.80
|
| Rate for Payer: Cigna Commercial |
$4,316.30
|
| Rate for Payer: First Health Commercial |
$4,570.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,570.20
|
| Rate for Payer: GEHA Commercial |
$3,554.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,570.20
|
| Rate for Payer: Multiplan All |
$4,620.98
|
| Rate for Payer: OMNI Networks Commercial |
$3,554.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,570.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,824.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,808.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,722.54
|
| Rate for Payer: Zelis Auto |
$2,031.20
|
|
|
IMPLT GLENOSPHERE 36MM
|
Facility
|
OP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001843
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.75 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,532.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Humana ChoiceCare |
$1,147.90
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,649.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,885.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,103.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,207.50
|
|
|
IMPLT GLENOSPHERE 36MM
|
Facility
|
IP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001843
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,532.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,090.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 32X2MM
|
Facility
|
OP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.75 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$5,519.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Humana ChoiceCare |
$1,793.74
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,139.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,071.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,724.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,449.50
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 32X2MM
|
Facility
|
IP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,759.60 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,519.20
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$4,829.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 32X6MM
|
Facility
|
OP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002553
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.75 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$5,519.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Humana ChoiceCare |
$1,793.74
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,139.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,071.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,724.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,449.50
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 32X6MM
|
Facility
|
IP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002553
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,759.60 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,519.20
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$4,829.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 36MM
|
Facility
|
OP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.75 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$5,519.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Humana ChoiceCare |
$1,793.74
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,139.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,071.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,724.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,449.50
|
|
|
IMPLT GLENOSPHERE CONCENTRIC 36MM
|
Facility
|
IP
|
$6,899.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,759.60 |
| Max. Negotiated Rate |
$6,554.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,519.20
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cash Price |
$4,139.40
|
| Rate for Payer: Cigna Commercial |
$5,864.15
|
| Rate for Payer: First Health Commercial |
$6,209.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,209.10
|
| Rate for Payer: GEHA Commercial |
$4,829.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,209.10
|
| Rate for Payer: Multiplan All |
$6,278.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,829.30
|
| Rate for Payer: One Health Plan PPO/POS |
$6,209.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,554.05
|
| Rate for Payer: Three Rivers Provider Network All |
$5,174.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,416.07
|
| Rate for Payer: Zelis Auto |
$2,759.60
|
|
