|
IMPLT LINER CEMENTLESS 46MM
|
Facility
|
IP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,558.00 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,116.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$2,726.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
|
|
IMPLT LINER CEMENTLESS 46MM
|
Facility
|
OP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$973.75 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$3,116.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Humana ChoiceCare |
$1,012.70
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,337.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,427.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$973.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,947.50
|
|
|
IMPLT LINER CEMENTLESS 48MM
|
Facility
|
IP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,558.00 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,116.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$2,726.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
|
|
IMPLT LINER CEMENTLESS 48MM
|
Facility
|
OP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$973.75 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$3,116.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Humana ChoiceCare |
$1,012.70
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,337.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,427.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$973.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,947.50
|
|
|
IMPLT LINER CEMENTLESS 52MM ALPH H
|
Facility
|
IP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,558.00 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,116.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$2,726.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
|
|
IMPLT LINER CEMENTLESS 52MM ALPH H
|
Facility
|
OP
|
$3,895.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$973.75 |
| Max. Negotiated Rate |
$3,700.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cash Price |
$2,337.00
|
| Rate for Payer: Cigna Commercial |
$3,310.75
|
| Rate for Payer: First Health Commercial |
$3,505.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,505.50
|
| Rate for Payer: GEHA Commercial |
$3,116.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,505.50
|
| Rate for Payer: Humana ChoiceCare |
$1,012.70
|
| Rate for Payer: Multiplan All |
$3,544.45
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,337.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,726.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,505.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,700.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,921.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,427.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$973.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,622.35
|
| Rate for Payer: Zelis Auto |
$1,558.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,947.50
|
|
|
IMPLT LINER ILS 8MM
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$600.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$525.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
|
|
IMPLT LINER ILS 8MM
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$712.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$637.50
|
| Rate for Payer: First Health Commercial |
$675.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.00
|
| Rate for Payer: GEHA Commercial |
$600.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.00
|
| Rate for Payer: Humana ChoiceCare |
$195.00
|
| Rate for Payer: Multiplan All |
$682.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$450.00
|
| Rate for Payer: OMNI Networks Commercial |
$525.00
|
| Rate for Payer: One Health Plan PPO/POS |
$675.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$712.50
|
| Rate for Payer: Three Rivers Provider Network All |
$562.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$660.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$187.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$697.50
|
| Rate for Payer: Zelis Auto |
$300.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$375.00
|
|
|
IMPLT LINER INSERT MDM 22.2MM 36MM 36C
|
Facility
|
OP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$894.50 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Humana ChoiceCare |
$930.28
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,146.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,148.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$894.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,789.00
|
|
|
IMPLT LINER INSERT MDM 22.2MM 36MM 36C
|
Facility
|
IP
|
$3,578.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,431.20 |
| Max. Negotiated Rate |
$3,399.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,862.40
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cash Price |
$2,146.80
|
| Rate for Payer: Cigna Commercial |
$3,041.30
|
| Rate for Payer: First Health Commercial |
$3,220.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,220.20
|
| Rate for Payer: GEHA Commercial |
$2,504.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,220.20
|
| Rate for Payer: Multiplan All |
$3,255.98
|
| Rate for Payer: OMNI Networks Commercial |
$2,504.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,220.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,399.10
|
| Rate for Payer: Three Rivers Provider Network All |
$2,683.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,327.54
|
| Rate for Payer: Zelis Auto |
$1,431.20
|
|
|
IMPLT LINER POLY 0MM OFFSET 36MM DIA
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$951.50 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$3,044.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Humana ChoiceCare |
$989.56
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,283.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,349.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$951.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,903.00
|
|
|
IMPLT LINER POLY 0MM OFFSET 36MM DIA
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.40 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,044.80
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$2,664.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
|
|
IMPLT LINER SHELL BIPOLAR 28MM
|
Facility
|
IP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.60 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.20
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,598.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
|
|
IMPLT LINER SHELL BIPOLAR 28MM
|
Facility
|
OP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002255
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$571.00 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,827.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Humana ChoiceCare |
$593.84
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,370.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,009.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$571.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,142.00
|
|
|
IMPLT LINER SHELL BIPOLAR 28X54MM
|
Facility
|
OP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$571.00 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,827.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Humana ChoiceCare |
$593.84
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,370.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,009.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$571.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,142.00
|
|
|
IMPLT LINER SHELL BIPOLAR 28X54MM
|
Facility
|
IP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.60 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.20
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,598.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
|
|
IMPLT LINER SHELL BIPOLAR 47X28MM
|
Facility
|
OP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002257
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$571.00 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,827.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Humana ChoiceCare |
$593.84
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,370.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,009.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$571.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,142.00
|
|
|
IMPLT LINER SHELL BIPOLAR 47X28MM
|
Facility
|
IP
|
$2,284.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002257
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.60 |
| Max. Negotiated Rate |
$2,169.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,827.20
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$1,941.40
|
| Rate for Payer: First Health Commercial |
$2,055.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,055.60
|
| Rate for Payer: GEHA Commercial |
$1,598.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,055.60
|
| Rate for Payer: Multiplan All |
$2,078.44
|
| Rate for Payer: OMNI Networks Commercial |
$1,598.80
|
| Rate for Payer: One Health Plan PPO/POS |
$2,055.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,169.80
|
| Rate for Payer: Three Rivers Provider Network All |
$1,713.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,124.12
|
| Rate for Payer: Zelis Auto |
$913.60
|
|
|
IMPLT LINER SHELL BIPOLAR 48OD 28ID
|
Facility
|
OP
|
$1,740.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,653.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cigna Commercial |
$1,479.00
|
| Rate for Payer: First Health Commercial |
$1,566.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,566.00
|
| Rate for Payer: GEHA Commercial |
$1,392.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,566.00
|
| Rate for Payer: Humana ChoiceCare |
$452.40
|
| Rate for Payer: Multiplan All |
$1,583.40
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,044.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,218.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,566.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,653.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,305.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,531.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$435.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,618.20
|
| Rate for Payer: Zelis Auto |
$696.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$870.00
|
|
|
IMPLT LINER SHELL BIPOLAR 48OD 28ID
|
Facility
|
IP
|
$1,740.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$696.00 |
| Max. Negotiated Rate |
$1,653.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,392.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cash Price |
$1,044.00
|
| Rate for Payer: Cigna Commercial |
$1,479.00
|
| Rate for Payer: First Health Commercial |
$1,566.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,566.00
|
| Rate for Payer: GEHA Commercial |
$1,218.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,566.00
|
| Rate for Payer: Multiplan All |
$1,583.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,218.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,566.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,653.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,305.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,618.20
|
| Rate for Payer: Zelis Auto |
$696.00
|
|
|
IMPLT LINER SHELL HOLE 3
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002094
|
|
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 SHELL HOLE 3
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002094
|
|
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 XLPE 40MM IDX58OD
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002259
|
|
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 XLPE 40MM IDX58OD
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002259
|
|
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 LNQ22 REVEAL LOOP RECORDER
|
Facility
|
OP
|
$16,885.00
|
|
|
Service Code
|
CPT C1764
|
| Hospital Charge Code |
7006665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,221.25 |
| Max. Negotiated Rate |
$16,040.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,131.00
|
| Rate for Payer: Cash Price |
$10,131.00
|
| Rate for Payer: Cash Price |
$10,131.00
|
| Rate for Payer: Cigna Commercial |
$14,352.25
|
| Rate for Payer: First Health Commercial |
$15,196.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$15,196.50
|
| Rate for Payer: GEHA Commercial |
$13,508.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$15,196.50
|
| Rate for Payer: Humana ChoiceCare |
$4,390.10
|
| Rate for Payer: Multiplan All |
$15,365.35
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,131.00
|
| Rate for Payer: OMNI Networks Commercial |
$11,819.50
|
| Rate for Payer: One Health Plan PPO/POS |
$15,196.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$16,040.75
|
| Rate for Payer: Three Rivers Provider Network All |
$12,663.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$14,858.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,221.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$15,703.05
|
| Rate for Payer: Zelis Auto |
$6,754.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$8,442.50
|
|
