|
IMPLT INSERT TIBIAL ONLAY SIZE 4 X8MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002060
|
|
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 ONLAY SIZE 5X8MM
|
Facility
|
IP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,644.40 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,288.80
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$2,877.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
|
|
IMPLT INSERT TIBIAL ONLAY SIZE 5X8MM
|
Facility
|
OP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,027.75 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$3,288.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Humana ChoiceCare |
$1,068.86
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,466.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,617.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,027.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,055.50
|
|
|
IMPLT INSERT TIBIAL ONLAY SIZE 5X8MM
|
Facility
|
OP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,027.75 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$3,288.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Humana ChoiceCare |
$1,068.86
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,466.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,617.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,027.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,055.50
|
|
|
IMPLT INSERT TIBIAL ONLAY SIZE 5X8MM
|
Facility
|
IP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,644.40 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,288.80
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$2,877.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
|
|
IMPLT INSERT TIBIAL ONLAY SIZE 7X10
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006784
|
|
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 ONLAY SIZE 7X10
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006784
|
|
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 ONLAY SIZE 7X9MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003279
|
|
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 ONLAY SIZE 7X9MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003279
|
|
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 ONLAY SIZE 8
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006687
|
|
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 ONLAY SIZE 8
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006687
|
|
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 ONLAY SIZE 8X9MM
|
Facility
|
IP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,644.40 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,288.80
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$2,877.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
|
|
IMPLT INSERT TIBIAL ONLAY SIZE 8X9MM
|
Facility
|
OP
|
$4,111.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,027.75 |
| Max. Negotiated Rate |
$3,905.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cash Price |
$2,466.60
|
| Rate for Payer: Cigna Commercial |
$3,494.35
|
| Rate for Payer: First Health Commercial |
$3,699.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,699.90
|
| Rate for Payer: GEHA Commercial |
$3,288.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,699.90
|
| Rate for Payer: Humana ChoiceCare |
$1,068.86
|
| Rate for Payer: Multiplan All |
$3,741.01
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,466.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,877.70
|
| Rate for Payer: One Health Plan PPO/POS |
$3,699.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,905.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,083.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,617.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,027.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,823.23
|
| Rate for Payer: Zelis Auto |
$1,644.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,055.50
|
|
|
IMPLT INSERT TIBIAL PLATFORM LG 12.5
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.00 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,980.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,232.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
|
|
IMPLT INSERT TIBIAL PLATFORM LG 12.5
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,868.75 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,980.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Humana ChoiceCare |
$1,943.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,485.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,578.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,868.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,737.50
|
|
|
IMPLT INSERT TIBIAL PLATFORM LG 15MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,868.75 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,980.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Humana ChoiceCare |
$1,943.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,485.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,578.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,868.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,737.50
|
|
|
IMPLT INSERT TIBIAL PLATFORM LG 15MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002206
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.00 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,980.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,232.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
|
|
IMPLT INSERT TIBIAL PLTF ROTING LRG.10MM
|
Facility
|
IP
|
$7,812.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,124.80 |
| Max. Negotiated Rate |
$7,421.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,249.60
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cigna Commercial |
$6,640.20
|
| Rate for Payer: First Health Commercial |
$7,030.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,030.80
|
| Rate for Payer: GEHA Commercial |
$5,468.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,030.80
|
| Rate for Payer: Multiplan All |
$7,108.92
|
| Rate for Payer: OMNI Networks Commercial |
$5,468.40
|
| Rate for Payer: One Health Plan PPO/POS |
$7,030.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,421.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,859.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,265.16
|
| Rate for Payer: Zelis Auto |
$3,124.80
|
|
|
IMPLT INSERT TIBIAL PLTF ROTING LRG.10MM
|
Facility
|
OP
|
$7,812.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.00 |
| Max. Negotiated Rate |
$7,421.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cigna Commercial |
$6,640.20
|
| Rate for Payer: First Health Commercial |
$7,030.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,030.80
|
| Rate for Payer: GEHA Commercial |
$6,249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,030.80
|
| Rate for Payer: Humana ChoiceCare |
$2,031.12
|
| Rate for Payer: Multiplan All |
$7,108.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,687.20
|
| Rate for Payer: OMNI Networks Commercial |
$5,468.40
|
| Rate for Payer: One Health Plan PPO/POS |
$7,030.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,421.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,859.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,874.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,953.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,265.16
|
| Rate for Payer: Zelis Auto |
$3,124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,906.00
|
|
|
IMPLT INSERT TIBIAL ROTATING 10MM
|
Facility
|
OP
|
$7,812.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.00 |
| Max. Negotiated Rate |
$7,421.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cigna Commercial |
$6,640.20
|
| Rate for Payer: First Health Commercial |
$7,030.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,030.80
|
| Rate for Payer: GEHA Commercial |
$6,249.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,030.80
|
| Rate for Payer: Humana ChoiceCare |
$2,031.12
|
| Rate for Payer: Multiplan All |
$7,108.92
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,687.20
|
| Rate for Payer: OMNI Networks Commercial |
$5,468.40
|
| Rate for Payer: One Health Plan PPO/POS |
$7,030.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,421.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,859.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,874.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,953.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,265.16
|
| Rate for Payer: Zelis Auto |
$3,124.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,906.00
|
|
|
IMPLT INSERT TIBIAL ROTATING 10MM
|
Facility
|
IP
|
$7,812.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,124.80 |
| Max. Negotiated Rate |
$7,421.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,249.60
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cash Price |
$4,687.20
|
| Rate for Payer: Cigna Commercial |
$6,640.20
|
| Rate for Payer: First Health Commercial |
$7,030.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,030.80
|
| Rate for Payer: GEHA Commercial |
$5,468.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,030.80
|
| Rate for Payer: Multiplan All |
$7,108.92
|
| Rate for Payer: OMNI Networks Commercial |
$5,468.40
|
| Rate for Payer: One Health Plan PPO/POS |
$7,030.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,421.40
|
| Rate for Payer: Three Rivers Provider Network All |
$5,859.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,265.16
|
| Rate for Payer: Zelis Auto |
$3,124.80
|
|
|
IMPLT INSERT TIBIAL SIZE 2
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,012.50 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$3,240.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Humana ChoiceCare |
$1,053.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,430.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,564.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,012.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,025.00
|
|
|
IMPLT INSERT TIBIAL SIZE 2
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,240.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$2,835.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
|
|
IMPLT INSERT TIBIAL SIZE 2,8MM
|
Facility
|
OP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.75 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,532.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Humana ChoiceCare |
$1,147.90
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,649.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,885.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,103.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,207.50
|
|
|
IMPLT INSERT TIBIAL SIZE 2,8MM
|
Facility
|
IP
|
$4,415.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002208
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,766.00 |
| Max. Negotiated Rate |
$4,194.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,532.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cash Price |
$2,649.00
|
| Rate for Payer: Cigna Commercial |
$3,752.75
|
| Rate for Payer: First Health Commercial |
$3,973.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,973.50
|
| Rate for Payer: GEHA Commercial |
$3,090.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,973.50
|
| Rate for Payer: Multiplan All |
$4,017.65
|
| Rate for Payer: OMNI Networks Commercial |
$3,090.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,973.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,194.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,311.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,105.95
|
| Rate for Payer: Zelis Auto |
$1,766.00
|
|
