|
IMPLT HEALICOIL KNOTLESS 5.0 NONSELF
|
Facility
|
IP
|
$1,472.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.80 |
| Max. Negotiated Rate |
$1,398.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,177.60
|
| Rate for Payer: Cash Price |
$883.20
|
| Rate for Payer: Cash Price |
$883.20
|
| Rate for Payer: Cigna Commercial |
$1,251.20
|
| Rate for Payer: First Health Commercial |
$1,324.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,324.80
|
| Rate for Payer: GEHA Commercial |
$1,030.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,324.80
|
| Rate for Payer: Multiplan All |
$1,339.52
|
| Rate for Payer: OMNI Networks Commercial |
$1,030.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,324.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,398.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,104.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,368.96
|
| Rate for Payer: Zelis Auto |
$588.80
|
|
|
IMPLT HEALICOIL KNOTLESS 5.0 SELF TAPPIN
|
Facility
|
OP
|
$2,406.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$601.50 |
| Max. Negotiated Rate |
$2,285.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,443.60
|
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cigna Commercial |
$2,045.10
|
| Rate for Payer: First Health Commercial |
$2,165.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.40
|
| Rate for Payer: GEHA Commercial |
$1,924.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.40
|
| Rate for Payer: Humana ChoiceCare |
$625.56
|
| Rate for Payer: Multiplan All |
$2,189.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,443.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,285.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,117.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$601.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.58
|
| Rate for Payer: Zelis Auto |
$962.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,203.00
|
|
|
IMPLT HEALICOIL KNOTLESS 5.0 SELF TAPPIN
|
Facility
|
IP
|
$2,406.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$962.40 |
| Max. Negotiated Rate |
$2,285.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,924.80
|
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cash Price |
$1,443.60
|
| Rate for Payer: Cigna Commercial |
$2,045.10
|
| Rate for Payer: First Health Commercial |
$2,165.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,165.40
|
| Rate for Payer: GEHA Commercial |
$1,684.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,165.40
|
| Rate for Payer: Multiplan All |
$2,189.46
|
| Rate for Payer: OMNI Networks Commercial |
$1,684.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,165.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,285.70
|
| Rate for Payer: Three Rivers Provider Network All |
$1,804.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,237.58
|
| Rate for Payer: Zelis Auto |
$962.40
|
|
|
IMPLT HEALICOIL REGEN 4.75 W/3 MINITAPES
|
Facility
|
OP
|
$2,590.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.50 |
| Max. Negotiated Rate |
$2,460.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,554.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: Cigna Commercial |
$2,201.50
|
| Rate for Payer: First Health Commercial |
$2,331.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,331.00
|
| Rate for Payer: GEHA Commercial |
$2,072.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,331.00
|
| Rate for Payer: Humana ChoiceCare |
$673.40
|
| Rate for Payer: Multiplan All |
$2,356.90
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,554.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,813.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,331.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,460.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,942.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,279.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$647.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,408.70
|
| Rate for Payer: Zelis Auto |
$1,036.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,295.00
|
|
|
IMPLT HEALICOIL REGEN 4.75 W/3 MINITAPES
|
Facility
|
IP
|
$2,590.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,036.00 |
| Max. Negotiated Rate |
$2,460.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,072.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: Cigna Commercial |
$2,201.50
|
| Rate for Payer: First Health Commercial |
$2,331.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,331.00
|
| Rate for Payer: GEHA Commercial |
$1,813.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,331.00
|
| Rate for Payer: Multiplan All |
$2,356.90
|
| Rate for Payer: OMNI Networks Commercial |
$1,813.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,331.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,460.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,942.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,408.70
|
| Rate for Payer: Zelis Auto |
$1,036.00
|
|
|
IMPLT HEMI-TOE REGULAR LPT
|
Facility
|
OP
|
$5,094.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,273.50 |
| Max. Negotiated Rate |
$4,839.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,056.40
|
| Rate for Payer: Cash Price |
$3,056.40
|
| Rate for Payer: Cash Price |
$3,056.40
|
| Rate for Payer: Cigna Commercial |
$4,329.90
|
| Rate for Payer: First Health Commercial |
$4,584.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,584.60
|
| Rate for Payer: GEHA Commercial |
$4,075.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,584.60
|
| Rate for Payer: Humana ChoiceCare |
$1,324.44
|
| Rate for Payer: Multiplan All |
$4,635.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,056.40
|
| Rate for Payer: OMNI Networks Commercial |
$3,565.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,584.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,839.30
|
| Rate for Payer: Three Rivers Provider Network All |
$3,820.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,482.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,273.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,737.42
|
| Rate for Payer: Zelis Auto |
$2,037.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,547.00
|
|
|
IMPLT HEMI-TOE REGULAR LPT
|
Facility
|
IP
|
$5,094.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,037.60 |
| Max. Negotiated Rate |
$4,839.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,075.20
|
| Rate for Payer: Cash Price |
$3,056.40
|
| Rate for Payer: Cash Price |
$3,056.40
|
| Rate for Payer: Cigna Commercial |
$4,329.90
|
| Rate for Payer: First Health Commercial |
$4,584.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,584.60
|
| Rate for Payer: GEHA Commercial |
$3,565.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,584.60
|
| Rate for Payer: Multiplan All |
$4,635.54
|
| Rate for Payer: OMNI Networks Commercial |
$3,565.80
|
| Rate for Payer: One Health Plan PPO/POS |
$4,584.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,839.30
|
| Rate for Payer: Three Rivers Provider Network All |
$3,820.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,737.42
|
| Rate for Payer: Zelis Auto |
$2,037.60
|
|
|
IMPLT HEX CHECKPOINT 3.5
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$274.00 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$479.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
|
|
IMPLT HEX CHECKPOINT 3.5
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
70001800
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.25 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$582.25
|
| Rate for Payer: First Health Commercial |
$616.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$616.50
|
| Rate for Payer: GEHA Commercial |
$548.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$616.50
|
| Rate for Payer: Humana ChoiceCare |
$178.10
|
| Rate for Payer: Multiplan All |
$623.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$411.00
|
| Rate for Payer: OMNI Networks Commercial |
$479.50
|
| Rate for Payer: One Health Plan PPO/POS |
$616.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$650.75
|
| Rate for Payer: Three Rivers Provider Network All |
$513.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$602.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$171.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$637.05
|
| Rate for Payer: Zelis Auto |
$274.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$342.50
|
|
|
IMPLT HOLE PLUG HEX
|
Facility
|
OP
|
$655.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.75 |
| Max. Negotiated Rate |
$622.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$556.75
|
| Rate for Payer: First Health Commercial |
$589.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$589.50
|
| Rate for Payer: GEHA Commercial |
$524.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$589.50
|
| Rate for Payer: Humana ChoiceCare |
$170.30
|
| Rate for Payer: Multiplan All |
$596.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$393.00
|
| Rate for Payer: OMNI Networks Commercial |
$458.50
|
| Rate for Payer: One Health Plan PPO/POS |
$589.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$622.25
|
| Rate for Payer: Three Rivers Provider Network All |
$491.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$576.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$163.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$609.15
|
| Rate for Payer: Zelis Auto |
$262.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$327.50
|
|
|
IMPLT HOLE PLUG HEX
|
Facility
|
IP
|
$655.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$262.00 |
| Max. Negotiated Rate |
$622.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$524.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$556.75
|
| Rate for Payer: First Health Commercial |
$589.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$589.50
|
| Rate for Payer: GEHA Commercial |
$458.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$589.50
|
| Rate for Payer: Multiplan All |
$596.05
|
| Rate for Payer: OMNI Networks Commercial |
$458.50
|
| Rate for Payer: One Health Plan PPO/POS |
$589.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$622.25
|
| Rate for Payer: Three Rivers Provider Network All |
$491.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$609.15
|
| Rate for Payer: Zelis Auto |
$262.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
OP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,920.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Humana ChoiceCare |
$1,599.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,690.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,412.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,537.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,075.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
OP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,920.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Humana ChoiceCare |
$1,599.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,690.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,412.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,537.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,075.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
IP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.00 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,920.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,305.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
OP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009224
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,920.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Humana ChoiceCare |
$1,599.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,690.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,412.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,537.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,075.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
IP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009224
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.00 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,920.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,305.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
OP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,920.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Humana ChoiceCare |
$1,599.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,690.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,412.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,537.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,075.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
IP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.00 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,920.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,305.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
|
|
IMPLT HUMERAL INSERT
|
Facility
|
IP
|
$6,150.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7009252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.00 |
| Max. Negotiated Rate |
$5,842.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,920.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$5,227.50
|
| Rate for Payer: First Health Commercial |
$5,535.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.00
|
| Rate for Payer: GEHA Commercial |
$4,305.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.00
|
| Rate for Payer: Multiplan All |
$5,596.50
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,842.50
|
| Rate for Payer: Three Rivers Provider Network All |
$4,612.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,719.50
|
| Rate for Payer: Zelis Auto |
$2,460.00
|
|
|
IMPLT HYDROSET 10CC
|
Facility
|
OP
|
$8,668.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,167.00 |
| Max. Negotiated Rate |
$8,234.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,200.80
|
| Rate for Payer: Cash Price |
$5,200.80
|
| Rate for Payer: Cash Price |
$5,200.80
|
| Rate for Payer: Cigna Commercial |
$7,367.80
|
| Rate for Payer: First Health Commercial |
$7,801.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,801.20
|
| Rate for Payer: GEHA Commercial |
$6,934.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,801.20
|
| Rate for Payer: Humana ChoiceCare |
$2,253.68
|
| Rate for Payer: Multiplan All |
$7,887.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,200.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,067.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,801.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,234.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,501.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,627.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,167.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,061.24
|
| Rate for Payer: Zelis Auto |
$3,467.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,334.00
|
|
|
IMPLT HYDROSET 10CC
|
Facility
|
IP
|
$8,668.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,467.20 |
| Max. Negotiated Rate |
$8,234.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,934.40
|
| Rate for Payer: Cash Price |
$5,200.80
|
| Rate for Payer: Cash Price |
$5,200.80
|
| Rate for Payer: Cigna Commercial |
$7,367.80
|
| Rate for Payer: First Health Commercial |
$7,801.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,801.20
|
| Rate for Payer: GEHA Commercial |
$6,067.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,801.20
|
| Rate for Payer: Multiplan All |
$7,887.88
|
| Rate for Payer: OMNI Networks Commercial |
$6,067.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,801.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,234.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6,501.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,061.24
|
| Rate for Payer: Zelis Auto |
$3,467.20
|
|
|
IMPLT HYDROSET 15CC
|
Facility
|
IP
|
$11,366.43
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,546.57 |
| Max. Negotiated Rate |
$10,798.11 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,093.14
|
| Rate for Payer: Cash Price |
$6,819.86
|
| Rate for Payer: Cash Price |
$6,819.86
|
| Rate for Payer: Cigna Commercial |
$9,661.47
|
| Rate for Payer: First Health Commercial |
$10,229.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,229.79
|
| Rate for Payer: GEHA Commercial |
$7,956.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,229.79
|
| Rate for Payer: Multiplan All |
$10,343.45
|
| Rate for Payer: OMNI Networks Commercial |
$7,956.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,229.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,798.11
|
| Rate for Payer: Three Rivers Provider Network All |
$8,524.82
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,570.78
|
| Rate for Payer: Zelis Auto |
$4,546.57
|
|
|
IMPLT HYDROSET 15CC
|
Facility
|
OP
|
$11,366.43
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003461
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,841.61 |
| Max. Negotiated Rate |
$10,798.11 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,819.86
|
| Rate for Payer: Cash Price |
$6,819.86
|
| Rate for Payer: Cash Price |
$6,819.86
|
| Rate for Payer: Cigna Commercial |
$9,661.47
|
| Rate for Payer: First Health Commercial |
$10,229.79
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,229.79
|
| Rate for Payer: GEHA Commercial |
$9,093.14
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,229.79
|
| Rate for Payer: Humana ChoiceCare |
$2,955.27
|
| Rate for Payer: Multiplan All |
$10,343.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,819.86
|
| Rate for Payer: OMNI Networks Commercial |
$7,956.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,229.79
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,798.11
|
| Rate for Payer: Three Rivers Provider Network All |
$8,524.82
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,002.46
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,841.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,570.78
|
| Rate for Payer: Zelis Auto |
$4,546.57
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,683.22
|
|
|
IMPLT HYDROSET 3CC
|
Facility
|
OP
|
$3,149.82
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003465
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$787.46 |
| Max. Negotiated Rate |
$2,992.33 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,889.89
|
| Rate for Payer: Cash Price |
$1,889.89
|
| Rate for Payer: Cigna Commercial |
$2,677.35
|
| Rate for Payer: First Health Commercial |
$2,834.84
|
| Rate for Payer: First Health Workers Compensation |
$1,216.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,834.84
|
| Rate for Payer: GEHA Commercial |
$2,519.86
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,834.84
|
| Rate for Payer: Humana ChoiceCare |
$818.95
|
| Rate for Payer: Multiplan All |
$2,866.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,889.89
|
| Rate for Payer: OMNI Networks Commercial |
$2,204.87
|
| Rate for Payer: One Health Plan PPO/POS |
$2,834.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,992.33
|
| Rate for Payer: Three Rivers Provider Network All |
$2,362.36
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,771.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$787.46
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,929.33
|
| Rate for Payer: Zelis Auto |
$1,259.93
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,574.91
|
| Rate for Payer: Zelis Worker's Compensation |
$859.90
|
|
|
IMPLT HYDROSET 3CC
|
Facility
|
IP
|
$3,149.82
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003465
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$859.90 |
| Max. Negotiated Rate |
$2,992.33 |
| Rate for Payer: Cash Price |
$1,889.89
|
| Rate for Payer: Cigna Commercial |
$2,677.35
|
| Rate for Payer: First Health Commercial |
$2,834.84
|
| Rate for Payer: First Health Workers Compensation |
$1,216.15
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,834.84
|
| Rate for Payer: GEHA Commercial |
$2,204.87
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,834.84
|
| Rate for Payer: Multiplan All |
$2,866.34
|
| Rate for Payer: OMNI Networks Commercial |
$2,204.87
|
| Rate for Payer: One Health Plan PPO/POS |
$2,834.84
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,992.33
|
| Rate for Payer: Three Rivers Provider Network All |
$2,362.36
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,929.33
|
| Rate for Payer: Zelis Auto |
$1,259.93
|
| Rate for Payer: Zelis Worker's Compensation |
$859.90
|
|
