|
IMPLT KIT NAIL TI 11X180MMX125
|
Facility
|
OP
|
$914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$731.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Humana ChoiceCare |
$237.64
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$548.40
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$804.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$228.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$457.00
|
|
|
IMPLT KIT NAIL TI 11X180MMX125
|
Facility
|
IP
|
$914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006342
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$365.60 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$731.20
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$639.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
|
|
IMPLT KIT NAIL TI 11X180MMX130
|
Facility
|
OP
|
$914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.50 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$731.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Humana ChoiceCare |
$237.64
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$548.40
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$804.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$228.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$457.00
|
|
|
IMPLT KIT NAIL TI 11X180MMX130
|
Facility
|
IP
|
$914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006343
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$365.60 |
| Max. Negotiated Rate |
$868.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$731.20
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cash Price |
$548.40
|
| Rate for Payer: Cigna Commercial |
$776.90
|
| Rate for Payer: First Health Commercial |
$822.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$822.60
|
| Rate for Payer: GEHA Commercial |
$639.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$822.60
|
| Rate for Payer: Multiplan All |
$831.74
|
| Rate for Payer: OMNI Networks Commercial |
$639.80
|
| Rate for Payer: One Health Plan PPO/POS |
$822.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$868.30
|
| Rate for Payer: Three Rivers Provider Network All |
$685.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$850.02
|
| Rate for Payer: Zelis Auto |
$365.60
|
|
|
IMPLT KIT NAIL TROC 10X170MMX130
|
Facility
|
OP
|
$5,131.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,282.75 |
| Max. Negotiated Rate |
$4,874.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,078.60
|
| Rate for Payer: Cash Price |
$3,078.60
|
| Rate for Payer: Cash Price |
$3,078.60
|
| Rate for Payer: Cigna Commercial |
$4,361.35
|
| Rate for Payer: First Health Commercial |
$4,617.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,617.90
|
| Rate for Payer: GEHA Commercial |
$4,104.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,617.90
|
| Rate for Payer: Humana ChoiceCare |
$1,334.06
|
| Rate for Payer: Multiplan All |
$4,669.21
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,078.60
|
| Rate for Payer: OMNI Networks Commercial |
$3,591.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,617.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,874.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,848.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,515.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,282.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,771.83
|
| Rate for Payer: Zelis Auto |
$2,052.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,565.50
|
|
|
IMPLT KIT NAIL TROC 10X170MMX130
|
Facility
|
IP
|
$5,131.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,052.40 |
| Max. Negotiated Rate |
$4,874.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,104.80
|
| Rate for Payer: Cash Price |
$3,078.60
|
| Rate for Payer: Cash Price |
$3,078.60
|
| Rate for Payer: Cigna Commercial |
$4,361.35
|
| Rate for Payer: First Health Commercial |
$4,617.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,617.90
|
| Rate for Payer: GEHA Commercial |
$3,591.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,617.90
|
| Rate for Payer: Multiplan All |
$4,669.21
|
| Rate for Payer: OMNI Networks Commercial |
$3,591.70
|
| Rate for Payer: One Health Plan PPO/POS |
$4,617.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,874.45
|
| Rate for Payer: Three Rivers Provider Network All |
$3,848.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,771.83
|
| Rate for Payer: Zelis Auto |
$2,052.40
|
|
|
IMPLT KIT PIN ORTHOSORB 1.3MM
|
Facility
|
OP
|
$889.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$222.25 |
| Max. Negotiated Rate |
$844.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cigna Commercial |
$755.65
|
| Rate for Payer: First Health Commercial |
$800.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$800.10
|
| Rate for Payer: GEHA Commercial |
$711.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$800.10
|
| Rate for Payer: Humana ChoiceCare |
$231.14
|
| Rate for Payer: Multiplan All |
$808.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$533.40
|
| Rate for Payer: OMNI Networks Commercial |
$622.30
|
| Rate for Payer: One Health Plan PPO/POS |
$800.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$844.55
|
| Rate for Payer: Three Rivers Provider Network All |
$666.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$782.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$222.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$826.77
|
| Rate for Payer: Zelis Auto |
$355.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$444.50
|
|
|
IMPLT KIT PIN ORTHOSORB 1.3MM
|
Facility
|
IP
|
$889.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$355.60 |
| Max. Negotiated Rate |
$844.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$711.20
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cash Price |
$533.40
|
| Rate for Payer: Cigna Commercial |
$755.65
|
| Rate for Payer: First Health Commercial |
$800.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$800.10
|
| Rate for Payer: GEHA Commercial |
$622.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$800.10
|
| Rate for Payer: Multiplan All |
$808.99
|
| Rate for Payer: OMNI Networks Commercial |
$622.30
|
| Rate for Payer: One Health Plan PPO/POS |
$800.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$844.55
|
| Rate for Payer: Three Rivers Provider Network All |
$666.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$826.77
|
| Rate for Payer: Zelis Auto |
$355.60
|
|
|
IMPLT KIT PREP FEMORAL SIZE 4
|
Facility
|
IP
|
$901.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$360.40 |
| Max. Negotiated Rate |
$855.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$720.80
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cigna Commercial |
$765.85
|
| Rate for Payer: First Health Commercial |
$810.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$810.90
|
| Rate for Payer: GEHA Commercial |
$630.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$810.90
|
| Rate for Payer: Multiplan All |
$819.91
|
| Rate for Payer: OMNI Networks Commercial |
$630.70
|
| Rate for Payer: One Health Plan PPO/POS |
$810.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$855.95
|
| Rate for Payer: Three Rivers Provider Network All |
$675.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$837.93
|
| Rate for Payer: Zelis Auto |
$360.40
|
|
|
IMPLT KIT PREP FEMORAL SIZE 4
|
Facility
|
OP
|
$901.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003006
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$225.25 |
| Max. Negotiated Rate |
$855.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$540.60
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cash Price |
$540.60
|
| Rate for Payer: Cigna Commercial |
$765.85
|
| Rate for Payer: First Health Commercial |
$810.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$810.90
|
| Rate for Payer: GEHA Commercial |
$720.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$810.90
|
| Rate for Payer: Humana ChoiceCare |
$234.26
|
| Rate for Payer: Multiplan All |
$819.91
|
| Rate for Payer: New Mexico Health Connections Medicare |
$540.60
|
| Rate for Payer: OMNI Networks Commercial |
$630.70
|
| Rate for Payer: One Health Plan PPO/POS |
$810.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$855.95
|
| Rate for Payer: Three Rivers Provider Network All |
$675.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$792.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$225.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$837.93
|
| Rate for Payer: Zelis Auto |
$360.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$450.50
|
|
|
IMPLT KIT PREP FEMORAL SIZE 5
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.50 |
| Max. Negotiated Rate |
$602.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cigna Commercial |
$538.90
|
| Rate for Payer: First Health Commercial |
$570.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$570.60
|
| Rate for Payer: GEHA Commercial |
$507.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$570.60
|
| Rate for Payer: Humana ChoiceCare |
$164.84
|
| Rate for Payer: Multiplan All |
$576.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$380.40
|
| Rate for Payer: OMNI Networks Commercial |
$443.80
|
| Rate for Payer: One Health Plan PPO/POS |
$570.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$602.30
|
| Rate for Payer: Three Rivers Provider Network All |
$475.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$557.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$158.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$589.62
|
| Rate for Payer: Zelis Auto |
$253.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$317.00
|
|
|
IMPLT KIT PREP FEMORAL SIZE 5
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$253.60 |
| Max. Negotiated Rate |
$602.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$507.20
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cigna Commercial |
$538.90
|
| Rate for Payer: First Health Commercial |
$570.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$570.60
|
| Rate for Payer: GEHA Commercial |
$443.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$570.60
|
| Rate for Payer: Multiplan All |
$576.94
|
| Rate for Payer: OMNI Networks Commercial |
$443.80
|
| Rate for Payer: One Health Plan PPO/POS |
$570.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$602.30
|
| Rate for Payer: Three Rivers Provider Network All |
$475.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$589.62
|
| Rate for Payer: Zelis Auto |
$253.60
|
|
|
IMPLT KIT PREP FEMORAL SIZE 6
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$253.60 |
| Max. Negotiated Rate |
$602.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$507.20
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cigna Commercial |
$538.90
|
| Rate for Payer: First Health Commercial |
$570.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$570.60
|
| Rate for Payer: GEHA Commercial |
$443.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$570.60
|
| Rate for Payer: Multiplan All |
$576.94
|
| Rate for Payer: OMNI Networks Commercial |
$443.80
|
| Rate for Payer: One Health Plan PPO/POS |
$570.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$602.30
|
| Rate for Payer: Three Rivers Provider Network All |
$475.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$589.62
|
| Rate for Payer: Zelis Auto |
$253.60
|
|
|
IMPLT KIT PREP FEMORAL SIZE 6
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002715
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.50 |
| Max. Negotiated Rate |
$602.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cash Price |
$380.40
|
| Rate for Payer: Cigna Commercial |
$538.90
|
| Rate for Payer: First Health Commercial |
$570.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$570.60
|
| Rate for Payer: GEHA Commercial |
$507.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$570.60
|
| Rate for Payer: Humana ChoiceCare |
$164.84
|
| Rate for Payer: Multiplan All |
$576.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$380.40
|
| Rate for Payer: OMNI Networks Commercial |
$443.80
|
| Rate for Payer: One Health Plan PPO/POS |
$570.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$602.30
|
| Rate for Payer: Three Rivers Provider Network All |
$475.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$557.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$158.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$589.62
|
| Rate for Payer: Zelis Auto |
$253.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$317.00
|
|
|
IMPLT KIT PREP TIBIAL SIZE 6
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002714
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$124.25 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$397.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Humana ChoiceCare |
$129.22
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$298.20
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$437.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: Zelis Auto |
$198.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$248.50
|
|
|
IMPLT KIT PREP TIBIAL SIZE 6
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002714
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$397.60
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$347.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: Zelis Auto |
$198.80
|
|
|
IMPLT KIT PREP TIBIAL SIZE 7
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$397.60
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$347.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: Zelis Auto |
$198.80
|
|
|
IMPLT KIT PREP TIBIAL SIZE 7
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$124.25 |
| Max. Negotiated Rate |
$472.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cigna Commercial |
$422.45
|
| Rate for Payer: First Health Commercial |
$447.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$447.30
|
| Rate for Payer: GEHA Commercial |
$397.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$447.30
|
| Rate for Payer: Humana ChoiceCare |
$129.22
|
| Rate for Payer: Multiplan All |
$452.27
|
| Rate for Payer: New Mexico Health Connections Medicare |
$298.20
|
| Rate for Payer: OMNI Networks Commercial |
$347.90
|
| Rate for Payer: One Health Plan PPO/POS |
$447.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$472.15
|
| Rate for Payer: Three Rivers Provider Network All |
$372.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$437.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$462.21
|
| Rate for Payer: Zelis Auto |
$198.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$248.50
|
|
|
IMPLT KIT PUSHLOCK 2.9MM BIOCOMPOSITE
|
Facility
|
IP
|
$964.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$385.60 |
| Max. Negotiated Rate |
$915.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$771.20
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$674.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
|
|
IMPLT KIT PUSHLOCK 2.9MM BIOCOMPOSITE
|
Facility
|
OP
|
$964.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$915.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Cigna Commercial |
$819.40
|
| Rate for Payer: First Health Commercial |
$867.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$867.60
|
| Rate for Payer: GEHA Commercial |
$771.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$867.60
|
| Rate for Payer: Humana ChoiceCare |
$250.64
|
| Rate for Payer: Multiplan All |
$877.24
|
| Rate for Payer: New Mexico Health Connections Medicare |
$578.40
|
| Rate for Payer: OMNI Networks Commercial |
$674.80
|
| Rate for Payer: One Health Plan PPO/POS |
$867.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$915.80
|
| Rate for Payer: Three Rivers Provider Network All |
$723.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$848.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$241.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$896.52
|
| Rate for Payer: Zelis Auto |
$385.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$482.00
|
|
|
IMPLT KIT REPAIR AUG LGMNT H/W INT BRACE
|
Facility
|
OP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003303
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.25 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Humana ChoiceCare |
$1,888.90
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,359.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,393.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,816.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,632.50
|
|
|
IMPLT KIT REPAIR AUG LGMNT H/W INT BRACE
|
Facility
|
IP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003303
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,906.00 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,812.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,085.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
|
|
IMPLT KIT SPEAR METAL WITH SUTURETAK-BIO
|
Facility
|
OP
|
$1,183.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006418
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$1,123.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$709.80
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cigna Commercial |
$1,005.55
|
| Rate for Payer: First Health Commercial |
$1,064.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,064.70
|
| Rate for Payer: GEHA Commercial |
$946.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,064.70
|
| Rate for Payer: Humana ChoiceCare |
$307.58
|
| Rate for Payer: Multiplan All |
$1,076.53
|
| Rate for Payer: New Mexico Health Connections Medicare |
$709.80
|
| Rate for Payer: OMNI Networks Commercial |
$828.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,064.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,123.85
|
| Rate for Payer: Three Rivers Provider Network All |
$887.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,041.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$295.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,100.19
|
| Rate for Payer: Zelis Auto |
$473.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$591.50
|
|
|
IMPLT KIT SPEAR METAL WITH SUTURETAK-BIO
|
Facility
|
IP
|
$1,183.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006418
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$473.20 |
| Max. Negotiated Rate |
$1,123.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$946.40
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cigna Commercial |
$1,005.55
|
| Rate for Payer: First Health Commercial |
$1,064.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,064.70
|
| Rate for Payer: GEHA Commercial |
$828.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,064.70
|
| Rate for Payer: Multiplan All |
$1,076.53
|
| Rate for Payer: OMNI Networks Commercial |
$828.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,064.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,123.85
|
| Rate for Payer: Three Rivers Provider Network All |
$887.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,100.19
|
| Rate for Payer: Zelis Auto |
$473.20
|
|
|
IMPLT KIT V-PROBE ENDOCARE/CRYO
|
Facility
|
IP
|
$15,986.00
|
|
|
Service Code
|
CPT C2618
|
| Hospital Charge Code |
7002449
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,394.40 |
| Max. Negotiated Rate |
$15,186.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$12,788.80
|
| Rate for Payer: Cash Price |
$9,591.60
|
| Rate for Payer: Cash Price |
$9,591.60
|
| Rate for Payer: Cigna Commercial |
$13,588.10
|
| Rate for Payer: First Health Commercial |
$14,387.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$14,387.40
|
| Rate for Payer: GEHA Commercial |
$11,190.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$14,387.40
|
| Rate for Payer: Multiplan All |
$14,547.26
|
| Rate for Payer: OMNI Networks Commercial |
$11,190.20
|
| Rate for Payer: One Health Plan PPO/POS |
$14,387.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$15,186.70
|
| Rate for Payer: Three Rivers Provider Network All |
$11,989.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$14,866.98
|
| Rate for Payer: Zelis Auto |
$6,394.40
|
|
