|
IMPLT LINER 10 DEGREE 32MM SIZE23
|
Facility
|
OP
|
$3,456.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002239
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$864.00 |
| Max. Negotiated Rate |
$3,283.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna Commercial |
$2,937.60
|
| Rate for Payer: First Health Commercial |
$3,110.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,110.40
|
| Rate for Payer: GEHA Commercial |
$2,764.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,110.40
|
| Rate for Payer: Humana ChoiceCare |
$898.56
|
| Rate for Payer: Multiplan All |
$3,144.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,073.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,419.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,110.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,283.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,592.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,041.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$864.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,214.08
|
| Rate for Payer: Zelis Auto |
$1,382.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,728.00
|
|
|
IMPLT LINER 10 DEGREE 32MM SIZE23
|
Facility
|
IP
|
$3,456.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002239
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,382.40 |
| Max. Negotiated Rate |
$3,283.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,764.80
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna Commercial |
$2,937.60
|
| Rate for Payer: First Health Commercial |
$3,110.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,110.40
|
| Rate for Payer: GEHA Commercial |
$2,419.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,110.40
|
| Rate for Payer: Multiplan All |
$3,144.96
|
| Rate for Payer: OMNI Networks Commercial |
$2,419.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,110.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,283.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,592.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,214.08
|
| Rate for Payer: Zelis Auto |
$1,382.40
|
|
|
IMPLT LINER 40MM 20 DEGREE
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER 40MM 20 DEGREE
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER 40MM SIZE 10 DEGREE
|
Facility
|
OP
|
$4,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.75 |
| Max. Negotiated Rate |
$3,954.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,497.80
|
| Rate for Payer: Cash Price |
$2,497.80
|
| Rate for Payer: Cash Price |
$2,497.80
|
| Rate for Payer: Cigna Commercial |
$3,538.55
|
| Rate for Payer: First Health Commercial |
$3,746.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,746.70
|
| Rate for Payer: GEHA Commercial |
$3,330.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,746.70
|
| Rate for Payer: Humana ChoiceCare |
$1,082.38
|
| Rate for Payer: Multiplan All |
$3,788.33
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,497.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,914.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,746.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,954.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,122.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,663.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,040.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,871.59
|
| Rate for Payer: Zelis Auto |
$1,665.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,081.50
|
|
|
IMPLT LINER 40MM SIZE 10 DEGREE
|
Facility
|
IP
|
$4,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,665.20 |
| Max. Negotiated Rate |
$3,954.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,330.40
|
| Rate for Payer: Cash Price |
$2,497.80
|
| Rate for Payer: Cash Price |
$2,497.80
|
| Rate for Payer: Cigna Commercial |
$3,538.55
|
| Rate for Payer: First Health Commercial |
$3,746.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,746.70
|
| Rate for Payer: GEHA Commercial |
$2,914.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,746.70
|
| Rate for Payer: Multiplan All |
$3,788.33
|
| Rate for Payer: OMNI Networks Commercial |
$2,914.10
|
| Rate for Payer: One Health Plan PPO/POS |
$3,746.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,954.85
|
| Rate for Payer: Three Rivers Provider Network All |
$3,122.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,871.59
|
| Rate for Payer: Zelis Auto |
$1,665.20
|
|
|
IMPLT LINER 44MM 20 DEGREE
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER 44MM 20 DEGREE
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002241
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER 52 OFFSET 7MM 36MM
|
Facility
|
OP
|
$5,999.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002242
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,499.75 |
| Max. Negotiated Rate |
$5,699.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cigna Commercial |
$5,099.15
|
| Rate for Payer: First Health Commercial |
$5,399.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,399.10
|
| Rate for Payer: GEHA Commercial |
$4,799.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,399.10
|
| Rate for Payer: Humana ChoiceCare |
$1,559.74
|
| Rate for Payer: Multiplan All |
$5,459.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,599.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,199.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,399.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,699.05
|
| Rate for Payer: Three Rivers Provider Network All |
$4,499.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,279.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,499.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,579.07
|
| Rate for Payer: Zelis Auto |
$2,399.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,999.50
|
|
|
IMPLT LINER 52 OFFSET 7MM 36MM
|
Facility
|
IP
|
$5,999.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002242
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,399.60 |
| Max. Negotiated Rate |
$5,699.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,799.20
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cigna Commercial |
$5,099.15
|
| Rate for Payer: First Health Commercial |
$5,399.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,399.10
|
| Rate for Payer: GEHA Commercial |
$4,199.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,399.10
|
| Rate for Payer: Multiplan All |
$5,459.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,199.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,399.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,699.05
|
| Rate for Payer: Three Rivers Provider Network All |
$4,499.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,579.07
|
| Rate for Payer: Zelis Auto |
$2,399.60
|
|
|
IMPLT LINER 54MM THREE HOLE SHELL
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.50 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,680.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Humana ChoiceCare |
$871.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,010.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,948.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$837.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,675.00
|
|
|
IMPLT LINER 54MM THREE HOLE SHELL
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002244
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.00 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,680.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,345.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
|
|
IMPLT LINER 54 OFFSET 7MM 36MM
|
Facility
|
IP
|
$5,999.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,399.60 |
| Max. Negotiated Rate |
$5,699.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,799.20
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cigna Commercial |
$5,099.15
|
| Rate for Payer: First Health Commercial |
$5,399.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,399.10
|
| Rate for Payer: GEHA Commercial |
$4,199.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,399.10
|
| Rate for Payer: Multiplan All |
$5,459.09
|
| Rate for Payer: OMNI Networks Commercial |
$4,199.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,399.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,699.05
|
| Rate for Payer: Three Rivers Provider Network All |
$4,499.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,579.07
|
| Rate for Payer: Zelis Auto |
$2,399.60
|
|
|
IMPLT LINER 54 OFFSET 7MM 36MM
|
Facility
|
OP
|
$5,999.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,499.75 |
| Max. Negotiated Rate |
$5,699.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cash Price |
$3,599.40
|
| Rate for Payer: Cigna Commercial |
$5,099.15
|
| Rate for Payer: First Health Commercial |
$5,399.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,399.10
|
| Rate for Payer: GEHA Commercial |
$4,799.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,399.10
|
| Rate for Payer: Humana ChoiceCare |
$1,559.74
|
| Rate for Payer: Multiplan All |
$5,459.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,599.40
|
| Rate for Payer: OMNI Networks Commercial |
$4,199.30
|
| Rate for Payer: One Health Plan PPO/POS |
$5,399.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,699.05
|
| Rate for Payer: Three Rivers Provider Network All |
$4,499.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,279.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,499.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,579.07
|
| Rate for Payer: Zelis Auto |
$2,399.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,999.50
|
|
|
IMPLT LINER ACETABULAR
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER ACETABULAR
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER ACETABULAR 20 DEGREE 36X58MM
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER ACETABULAR 20 DEGREE 36X58MM
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER ACETABULAR 28MMX46
|
Facility
|
IP
|
$5,177.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002249
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,070.80 |
| Max. Negotiated Rate |
$4,918.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,141.60
|
| Rate for Payer: Cash Price |
$3,106.20
|
| Rate for Payer: Cash Price |
$3,106.20
|
| Rate for Payer: Cigna Commercial |
$4,400.45
|
| Rate for Payer: First Health Commercial |
$4,659.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,659.30
|
| Rate for Payer: GEHA Commercial |
$3,623.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,659.30
|
| Rate for Payer: Multiplan All |
$4,711.07
|
| Rate for Payer: OMNI Networks Commercial |
$3,623.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,659.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,918.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,882.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,814.61
|
| Rate for Payer: Zelis Auto |
$2,070.80
|
|
|
IMPLT LINER ACETABULAR 28MMX46
|
Facility
|
OP
|
$5,177.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002249
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.25 |
| Max. Negotiated Rate |
$4,918.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,106.20
|
| Rate for Payer: Cash Price |
$3,106.20
|
| Rate for Payer: Cash Price |
$3,106.20
|
| Rate for Payer: Cigna Commercial |
$4,400.45
|
| Rate for Payer: First Health Commercial |
$4,659.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,659.30
|
| Rate for Payer: GEHA Commercial |
$4,141.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,659.30
|
| Rate for Payer: Humana ChoiceCare |
$1,346.02
|
| Rate for Payer: Multiplan All |
$4,711.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,106.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,623.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,659.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,918.15
|
| Rate for Payer: Three Rivers Provider Network All |
$3,882.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,555.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,294.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,814.61
|
| Rate for Payer: Zelis Auto |
$2,070.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,588.50
|
|
|
IMPLT LINER ACETABULAR 32X48MM
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER ACETABULAR 32X48MM
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER ACETABULAR 32X50MM
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.00 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,420.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Humana ChoiceCare |
$461.76
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,065.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,562.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$444.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$888.00
|
|
|
IMPLT LINER ACETABULAR 32X50MM
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
|
IMPLT LINER ACETABULAR 36X52MM
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.40 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,420.80
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cigna Commercial |
$1,509.60
|
| Rate for Payer: First Health Commercial |
$1,598.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,598.40
|
| Rate for Payer: GEHA Commercial |
$1,243.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,598.40
|
| Rate for Payer: Multiplan All |
$1,616.16
|
| Rate for Payer: OMNI Networks Commercial |
$1,243.20
|
| Rate for Payer: One Health Plan PPO/POS |
$1,598.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,687.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,332.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,651.68
|
| Rate for Payer: Zelis Auto |
$710.40
|
|
