|
IMPLT INSERT RESTORATION X3 42E 28/48
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007043
|
|
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 RESTORATION X3 48G SIZE
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002049
|
|
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 RESTORATION X3 48G SIZE
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002049
|
|
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 RESTORATION X3 52H 28/58
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003398
|
|
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 RESTORATION X3 52H 28/58
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003398
|
|
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 STABILIZER TIBIAL SIZE 6
|
Facility
|
IP
|
$10,853.40
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,341.36 |
| Max. Negotiated Rate |
$10,310.73 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,682.72
|
| Rate for Payer: Cash Price |
$6,512.04
|
| Rate for Payer: Cash Price |
$6,512.04
|
| Rate for Payer: Cigna Commercial |
$9,225.39
|
| Rate for Payer: First Health Commercial |
$9,768.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,768.06
|
| Rate for Payer: GEHA Commercial |
$7,597.38
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,768.06
|
| Rate for Payer: Multiplan All |
$9,876.59
|
| Rate for Payer: OMNI Networks Commercial |
$7,597.38
|
| Rate for Payer: One Health Plan PPO/POS |
$9,768.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,310.73
|
| Rate for Payer: Three Rivers Provider Network All |
$8,140.05
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,093.66
|
| Rate for Payer: Zelis Auto |
$4,341.36
|
|
|
IMPLT INSERT STABILIZER TIBIAL SIZE 6
|
Facility
|
OP
|
$10,853.40
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006791
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,713.35 |
| Max. Negotiated Rate |
$10,310.73 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,512.04
|
| Rate for Payer: Cash Price |
$6,512.04
|
| Rate for Payer: Cash Price |
$6,512.04
|
| Rate for Payer: Cigna Commercial |
$9,225.39
|
| Rate for Payer: First Health Commercial |
$9,768.06
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,768.06
|
| Rate for Payer: GEHA Commercial |
$8,682.72
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,768.06
|
| Rate for Payer: Humana ChoiceCare |
$2,821.88
|
| Rate for Payer: Multiplan All |
$9,876.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,512.04
|
| Rate for Payer: OMNI Networks Commercial |
$7,597.38
|
| Rate for Payer: One Health Plan PPO/POS |
$9,768.06
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,310.73
|
| Rate for Payer: Three Rivers Provider Network All |
$8,140.05
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9,550.99
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,713.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,093.66
|
| Rate for Payer: Zelis Auto |
$4,341.36
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,426.70
|
|
|
IMPLT INSERT STABILIZER TIBIAL SIZE 6
|
Facility
|
IP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,734.40 |
| Max. Negotiated Rate |
$6,494.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,468.80
|
| Rate for Payer: Cash Price |
$4,101.60
|
| Rate for Payer: Cash Price |
$4,101.60
|
| Rate for Payer: Cigna Commercial |
$5,810.60
|
| Rate for Payer: First Health Commercial |
$6,152.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,152.40
|
| Rate for Payer: GEHA Commercial |
$4,785.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,152.40
|
| Rate for Payer: Multiplan All |
$6,220.76
|
| Rate for Payer: OMNI Networks Commercial |
$4,785.20
|
| Rate for Payer: One Health Plan PPO/POS |
$6,152.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,494.20
|
| Rate for Payer: Three Rivers Provider Network All |
$5,127.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,357.48
|
| Rate for Payer: Zelis Auto |
$2,734.40
|
|
|
IMPLT INSERT STABILIZER TIBIAL SIZE 6
|
Facility
|
OP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,709.00 |
| Max. Negotiated Rate |
$6,494.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,101.60
|
| Rate for Payer: Cash Price |
$4,101.60
|
| Rate for Payer: Cash Price |
$4,101.60
|
| Rate for Payer: Cigna Commercial |
$5,810.60
|
| Rate for Payer: First Health Commercial |
$6,152.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,152.40
|
| Rate for Payer: GEHA Commercial |
$5,468.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,152.40
|
| Rate for Payer: Humana ChoiceCare |
$1,777.36
|
| Rate for Payer: Multiplan All |
$6,220.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,101.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,785.20
|
| Rate for Payer: One Health Plan PPO/POS |
$6,152.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,494.20
|
| Rate for Payer: Three Rivers Provider Network All |
$5,127.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,015.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,709.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,357.48
|
| Rate for Payer: Zelis Auto |
$2,734.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,418.00
|
|
|
IMPLT INSERT STABILIZER TOTAL #5 13MM
|
Facility
|
OP
|
$7,078.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.50 |
| Max. Negotiated Rate |
$6,724.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cigna Commercial |
$6,016.30
|
| Rate for Payer: First Health Commercial |
$6,370.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,370.20
|
| Rate for Payer: GEHA Commercial |
$5,662.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,370.20
|
| Rate for Payer: Humana ChoiceCare |
$1,840.28
|
| Rate for Payer: Multiplan All |
$6,440.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,246.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,954.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,370.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,724.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,308.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,228.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,769.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,582.54
|
| Rate for Payer: Zelis Auto |
$2,831.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,539.00
|
|
|
IMPLT INSERT STABILIZER TOTAL #5 13MM
|
Facility
|
IP
|
$7,078.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,831.20 |
| Max. Negotiated Rate |
$6,724.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,662.40
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cigna Commercial |
$6,016.30
|
| Rate for Payer: First Health Commercial |
$6,370.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,370.20
|
| Rate for Payer: GEHA Commercial |
$4,954.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,370.20
|
| Rate for Payer: Multiplan All |
$6,440.98
|
| Rate for Payer: OMNI Networks Commercial |
$4,954.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,370.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,724.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,308.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,582.54
|
| Rate for Payer: Zelis Auto |
$2,831.20
|
|
|
IMPLT INSERT STABILIZER TOTAL 5 SIZE
|
Facility
|
OP
|
$7,078.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.50 |
| Max. Negotiated Rate |
$6,724.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cigna Commercial |
$6,016.30
|
| Rate for Payer: First Health Commercial |
$6,370.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,370.20
|
| Rate for Payer: GEHA Commercial |
$5,662.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,370.20
|
| Rate for Payer: Humana ChoiceCare |
$1,840.28
|
| Rate for Payer: Multiplan All |
$6,440.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,246.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,954.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,370.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,724.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,308.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,228.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,769.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,582.54
|
| Rate for Payer: Zelis Auto |
$2,831.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,539.00
|
|
|
IMPLT INSERT STABILIZER TOTAL 5 SIZE
|
Facility
|
IP
|
$7,078.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002734
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,831.20 |
| Max. Negotiated Rate |
$6,724.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,662.40
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cash Price |
$4,246.80
|
| Rate for Payer: Cigna Commercial |
$6,016.30
|
| Rate for Payer: First Health Commercial |
$6,370.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,370.20
|
| Rate for Payer: GEHA Commercial |
$4,954.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,370.20
|
| Rate for Payer: Multiplan All |
$6,440.98
|
| Rate for Payer: OMNI Networks Commercial |
$4,954.60
|
| Rate for Payer: One Health Plan PPO/POS |
$6,370.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,724.10
|
| Rate for Payer: Three Rivers Provider Network All |
$5,308.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,582.54
|
| Rate for Payer: Zelis Auto |
$2,831.20
|
|
|
IMPLT INSERT TIBIAL 5X8MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.40 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,044.80
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$2,664.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
|
|
IMPLT INSERT TIBIAL 5X8MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$951.50 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$3,044.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Humana ChoiceCare |
$989.56
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,283.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,349.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$951.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,903.00
|
|
|
IMPLT INSERT TIBIAL 6X10MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$951.50 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$3,044.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Humana ChoiceCare |
$989.56
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,283.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,349.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$951.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,903.00
|
|
|
IMPLT INSERT TIBIAL 6X10MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006186
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.40 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,044.80
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$2,664.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
|
|
IMPLT INSERT TIBIAL BEARING 4 SIZE 16MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002688
|
|
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 TIBIAL BEARING 4 SIZE 16MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002688
|
|
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 TIBIAL BEARING 7 SIZE
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002222
|
|
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 TIBIAL BEARING 7 SIZE
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002222
|
|
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 TIBIAL BEARING CR SZ 5 11MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003374
|
|
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 TIBIAL BEARING CR SZ 5 11MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003440
|
|
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 TIBIAL BEARING CR SZ 5 11MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003440
|
|
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 TIBIAL BEARING CR SZ 5 11MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003374
|
|
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
|
|
