|
IMPLT INSERT TIBIAL STABIL TOTAL #7 13MM
|
Facility
|
OP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003112
|
|
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 TIBIAL STABIL TOTAL #7 13MM
|
Facility
|
IP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003112
|
|
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 TIBIAL STABIL TOTAL #8 13MM
|
Facility
|
IP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003111
|
|
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 TIBIAL STABIL TOTAL #8 13MM
|
Facility
|
OP
|
$6,836.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003111
|
|
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 TIBIAL STANDARD 10MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002215
|
|
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 STANDARD 10MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002215
|
|
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 STANDARD 15MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002216
|
|
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 STANDARD 15MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002216
|
|
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 TOTAL STABILIZER SZ5
|
Facility
|
IP
|
$7,078.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002192
|
|
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 TOTAL STABILIZER SZ5
|
Facility
|
OP
|
$7,078.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002192
|
|
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 TIBIAL TRIATHLON SIZE 5
|
Facility
|
IP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,442.00 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,884.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,273.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
|
|
IMPLT INSERT TIBIAL TRIATHLON SIZE 5
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002068
|
|
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 TRIATHLON SIZE 5
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002068
|
|
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 TRIATHLON SIZE 5
|
Facility
|
OP
|
$6,105.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,526.25 |
| Max. Negotiated Rate |
$5,799.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,663.00
|
| Rate for Payer: Cigna Commercial |
$5,189.25
|
| Rate for Payer: First Health Commercial |
$5,494.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,494.50
|
| Rate for Payer: GEHA Commercial |
$4,884.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,494.50
|
| Rate for Payer: Humana ChoiceCare |
$1,587.30
|
| Rate for Payer: Multiplan All |
$5,555.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,663.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,273.50
|
| Rate for Payer: One Health Plan PPO/POS |
$5,494.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,799.75
|
| Rate for Payer: Three Rivers Provider Network All |
$4,578.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,372.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,526.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,677.65
|
| Rate for Payer: Zelis Auto |
$2,442.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,052.50
|
|
|
IMPLT INSERT TRIDENT 0 DEGREE 32MM
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT TRIDENT 0 DEGREE 32MM
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSERT TRIDENT 0 DEGREE 36MM
|
Facility
|
IP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.80 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,265.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
|
|
IMPLT INSERT TRIDENT 0 DEGREE 36MM
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$3,075.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cash Price |
$1,942.20
|
| Rate for Payer: Cigna Commercial |
$2,751.45
|
| Rate for Payer: First Health Commercial |
$2,913.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,913.30
|
| Rate for Payer: GEHA Commercial |
$2,589.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,913.30
|
| Rate for Payer: Humana ChoiceCare |
$841.62
|
| Rate for Payer: Multiplan All |
$2,945.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,942.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,265.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,913.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,075.15
|
| Rate for Payer: Three Rivers Provider Network All |
$2,427.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,848.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$809.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,010.41
|
| Rate for Payer: Zelis Auto |
$1,294.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,618.50
|
|
|
IMPLT INSPACE LARGE
|
Facility
|
IP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003435
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,586.80 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17,173.60
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$15,026.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
|
|
IMPLT INSPACE LARGE
|
Facility
|
OP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003435
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,366.75 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$17,173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Humana ChoiceCare |
$5,581.42
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12,880.20
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18,890.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,366.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10,733.50
|
|
|
IMPLT INSPACE MEDIUM
|
Facility
|
IP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003434
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,586.80 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17,173.60
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$15,026.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
|
|
IMPLT INSPACE MEDIUM
|
Facility
|
OP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003434
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,366.75 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$17,173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Humana ChoiceCare |
$5,581.42
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12,880.20
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18,890.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,366.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10,733.50
|
|
|
IMPLT INSPACE SMALL
|
Facility
|
OP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,366.75 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$17,173.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Humana ChoiceCare |
$5,581.42
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$12,880.20
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$18,890.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$5,366.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$10,733.50
|
|
|
IMPLT INSPACE SMALL
|
Facility
|
IP
|
$21,467.00
|
|
|
Service Code
|
CPT C1889
|
| Hospital Charge Code |
7003433
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,586.80 |
| Max. Negotiated Rate |
$20,393.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$17,173.60
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cash Price |
$12,880.20
|
| Rate for Payer: Cigna Commercial |
$18,246.95
|
| Rate for Payer: First Health Commercial |
$19,320.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$19,320.30
|
| Rate for Payer: GEHA Commercial |
$15,026.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$19,320.30
|
| Rate for Payer: Multiplan All |
$19,534.97
|
| Rate for Payer: OMNI Networks Commercial |
$15,026.90
|
| Rate for Payer: One Health Plan PPO/POS |
$19,320.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$20,393.65
|
| Rate for Payer: Three Rivers Provider Network All |
$16,100.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$19,964.31
|
| Rate for Payer: Zelis Auto |
$8,586.80
|
|
|
IMPLT INTERPHALANGEAL PROXIMAL SILICONE
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,000.00 |
| Max. Negotiated Rate |
$4,750.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,000.00
|
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Cigna Commercial |
$4,250.00
|
| Rate for Payer: First Health Commercial |
$4,500.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,500.00
|
| Rate for Payer: GEHA Commercial |
$3,500.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,500.00
|
| Rate for Payer: Multiplan All |
$4,550.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,500.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,500.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,750.00
|
| Rate for Payer: Three Rivers Provider Network All |
$3,750.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,650.00
|
| Rate for Payer: Zelis Auto |
$2,000.00
|
|
