|
IMPLT INSERT BEARING TIBIAL SZ4 9MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 10MM CS
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003415
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 10MM CS
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003415
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 11MM-PS
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 11MM-PS
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 9MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002198
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ5 9MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002198
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 11MM CS
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 11MM CS
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 12MM CS
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003432
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 12MM CS
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003432
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 13MM CS
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003311
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BEARING TIBIAL SZ6 13MM CS
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003311
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ7 13MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002193
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT INSERT BEARING TIBIAL SZ7 13MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002193
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT INSERT BUMPER KNEE
|
Facility
|
OP
|
$2,320.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.00 |
| Max. Negotiated Rate |
$2,204.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,392.00
|
| Rate for Payer: Cash Price |
$1,392.00
|
| Rate for Payer: Cash Price |
$1,392.00
|
| Rate for Payer: Cigna Commercial |
$1,972.00
|
| Rate for Payer: First Health Commercial |
$2,088.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,088.00
|
| Rate for Payer: GEHA Commercial |
$1,856.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,088.00
|
| Rate for Payer: Humana ChoiceCare |
$603.20
|
| Rate for Payer: Multiplan All |
$2,111.20
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,392.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,624.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,088.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,204.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,740.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,041.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$580.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,157.60
|
| Rate for Payer: Zelis Auto |
$928.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,160.00
|
|
|
IMPLT INSERT BUMPER KNEE
|
Facility
|
IP
|
$2,320.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,204.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,856.00
|
| Rate for Payer: Cash Price |
$1,392.00
|
| Rate for Payer: Cash Price |
$1,392.00
|
| Rate for Payer: Cigna Commercial |
$1,972.00
|
| Rate for Payer: First Health Commercial |
$2,088.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,088.00
|
| Rate for Payer: GEHA Commercial |
$1,624.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,088.00
|
| Rate for Payer: Multiplan All |
$2,111.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,624.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,088.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,204.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,740.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,157.60
|
| Rate for Payer: Zelis Auto |
$928.00
|
|
|
IMPLT INSERT DISHED SIZE 3-4 11MM
|
Facility
|
IP
|
$411.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002189
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$164.40 |
| Max. Negotiated Rate |
$390.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$328.80
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$349.35
|
| Rate for Payer: First Health Commercial |
$369.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$369.90
|
| Rate for Payer: GEHA Commercial |
$287.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$369.90
|
| Rate for Payer: Multiplan All |
$374.01
|
| Rate for Payer: OMNI Networks Commercial |
$287.70
|
| Rate for Payer: One Health Plan PPO/POS |
$369.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.45
|
| Rate for Payer: Three Rivers Provider Network All |
$308.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.23
|
| Rate for Payer: Zelis Auto |
$164.40
|
|
|
IMPLT INSERT DISHED SIZE 3-4 11MM
|
Facility
|
OP
|
$411.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002189
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.75 |
| Max. Negotiated Rate |
$390.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$246.60
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$349.35
|
| Rate for Payer: First Health Commercial |
$369.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$369.90
|
| Rate for Payer: GEHA Commercial |
$328.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$369.90
|
| Rate for Payer: Humana ChoiceCare |
$106.86
|
| Rate for Payer: Multiplan All |
$374.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$246.60
|
| Rate for Payer: OMNI Networks Commercial |
$287.70
|
| Rate for Payer: One Health Plan PPO/POS |
$369.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$390.45
|
| Rate for Payer: Three Rivers Provider Network All |
$308.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$361.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$102.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$382.23
|
| Rate for Payer: Zelis Auto |
$164.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$205.50
|
|
|
IMPLT INSERT FEMORAL SZ5 9MM
|
Facility
|
OP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002199
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,211.75 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Humana ChoiceCare |
$1,260.22
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,908.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,211.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,423.50
|
|
|
IMPLT INSERT FEMORAL SZ5 9MM
|
Facility
|
IP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002199
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,938.80 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,877.60
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,392.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
|
|
IMPLT INSERT FOR MDM LINER
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.50 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Humana ChoiceCare |
$930.28
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,146.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,148.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$894.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,789.00
|
|
|
IMPLT INSERT FOR MDM LINER
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007044
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
|
IMPLT INSERT HUMERAL 32X8MM
|
Facility
|
OP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002552
|
|
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 INSERT HUMERAL 32X8MM
|
Facility
|
IP
|
$6,242.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002552
|
|
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
|
|
