|
IMPLT PATELLA ASYMMETRIC SIZE A32
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC SIZE A32
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA ASYMMETRIC SIZE A40
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC SIZE A40
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA ASYMMETRIC SIZE S33MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006640
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC SIZE S33MM
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006640
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA ASYMMETRIC TRIATH A38 11MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC TRIATH A38 11MM
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA ASYMMETRIC X3 A32 10MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC X3 A32 10MM
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA ASYMMETRIC X3 TRIATHION
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA ASYMMETRIC X3 TRIATHION
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA LCS LOW PROFILE LARGE
|
Facility
|
OP
|
$4,335.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.75 |
| Max. Negotiated Rate |
$4,118.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cigna Commercial |
$3,684.75
|
| Rate for Payer: First Health Commercial |
$3,901.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,901.50
|
| Rate for Payer: GEHA Commercial |
$3,468.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,901.50
|
| Rate for Payer: Humana ChoiceCare |
$1,127.10
|
| Rate for Payer: Multiplan All |
$3,944.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,601.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,034.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,901.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,118.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,251.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,814.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,083.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,031.55
|
| Rate for Payer: Zelis Auto |
$1,734.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,167.50
|
|
|
IMPLT PATELLA LCS LOW PROFILE LARGE
|
Facility
|
IP
|
$4,335.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$4,118.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,468.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cigna Commercial |
$3,684.75
|
| Rate for Payer: First Health Commercial |
$3,901.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,901.50
|
| Rate for Payer: GEHA Commercial |
$3,034.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,901.50
|
| Rate for Payer: Multiplan All |
$3,944.85
|
| Rate for Payer: OMNI Networks Commercial |
$3,034.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,901.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,118.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,251.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,031.55
|
| Rate for Payer: Zelis Auto |
$1,734.00
|
|
|
IMPLT PATELLA LOW PROFILE POLY LARGE
|
Facility
|
IP
|
$4,165.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,666.00 |
| Max. Negotiated Rate |
$3,956.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,332.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cigna Commercial |
$3,540.25
|
| Rate for Payer: First Health Commercial |
$3,748.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,748.50
|
| Rate for Payer: GEHA Commercial |
$2,915.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,748.50
|
| Rate for Payer: Multiplan All |
$3,790.15
|
| Rate for Payer: OMNI Networks Commercial |
$2,915.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,748.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,956.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,123.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,873.45
|
| Rate for Payer: Zelis Auto |
$1,666.00
|
|
|
IMPLT PATELLA LOW PROFILE POLY LARGE
|
Facility
|
OP
|
$4,165.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,041.25 |
| Max. Negotiated Rate |
$3,956.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,499.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cash Price |
$2,499.00
|
| Rate for Payer: Cigna Commercial |
$3,540.25
|
| Rate for Payer: First Health Commercial |
$3,748.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,748.50
|
| Rate for Payer: GEHA Commercial |
$3,332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,748.50
|
| Rate for Payer: Humana ChoiceCare |
$1,082.90
|
| Rate for Payer: Multiplan All |
$3,790.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,499.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,915.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,748.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,956.75
|
| Rate for Payer: Three Rivers Provider Network All |
$3,123.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,665.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,041.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,873.45
|
| Rate for Payer: Zelis Auto |
$1,666.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,082.50
|
|
|
IMPLT PATELLA OVAL RESURFACING 32MM
|
Facility
|
OP
|
$2,162.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.50 |
| Max. Negotiated Rate |
$2,053.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,297.20
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$1,837.70
|
| Rate for Payer: First Health Commercial |
$1,945.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,945.80
|
| Rate for Payer: GEHA Commercial |
$1,729.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,945.80
|
| Rate for Payer: Humana ChoiceCare |
$562.12
|
| Rate for Payer: Multiplan All |
$1,967.42
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,297.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,513.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,945.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,053.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,621.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,902.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$540.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,010.66
|
| Rate for Payer: Zelis Auto |
$864.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,081.00
|
|
|
IMPLT PATELLA OVAL RESURFACING 32MM
|
Facility
|
IP
|
$2,162.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$864.80 |
| Max. Negotiated Rate |
$2,053.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,729.60
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$1,837.70
|
| Rate for Payer: First Health Commercial |
$1,945.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,945.80
|
| Rate for Payer: GEHA Commercial |
$1,513.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,945.80
|
| Rate for Payer: Multiplan All |
$1,967.42
|
| Rate for Payer: OMNI Networks Commercial |
$1,513.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,945.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,053.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,621.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,010.66
|
| Rate for Payer: Zelis Auto |
$864.80
|
|
|
IMPLT PATELLA POLY LOW PROFILE
|
Facility
|
OP
|
$4,335.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.75 |
| Max. Negotiated Rate |
$4,118.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cigna Commercial |
$3,684.75
|
| Rate for Payer: First Health Commercial |
$3,901.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,901.50
|
| Rate for Payer: GEHA Commercial |
$3,468.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,901.50
|
| Rate for Payer: Humana ChoiceCare |
$1,127.10
|
| Rate for Payer: Multiplan All |
$3,944.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,601.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,034.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,901.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,118.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,251.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,814.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,083.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,031.55
|
| Rate for Payer: Zelis Auto |
$1,734.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,167.50
|
|
|
IMPLT PATELLA POLY LOW PROFILE
|
Facility
|
IP
|
$4,335.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002103
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$4,118.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,468.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cash Price |
$2,601.00
|
| Rate for Payer: Cigna Commercial |
$3,684.75
|
| Rate for Payer: First Health Commercial |
$3,901.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,901.50
|
| Rate for Payer: GEHA Commercial |
$3,034.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,901.50
|
| Rate for Payer: Multiplan All |
$3,944.85
|
| Rate for Payer: OMNI Networks Commercial |
$3,034.50
|
| Rate for Payer: One Health Plan PPO/POS |
$3,901.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,118.25
|
| Rate for Payer: Three Rivers Provider Network All |
$3,251.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,031.55
|
| Rate for Payer: Zelis Auto |
$1,734.00
|
|
|
IMPLT PATELLA STANDARD 8.5X34MM
|
Facility
|
OP
|
$3,636.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$909.00 |
| Max. Negotiated Rate |
$3,454.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,181.60
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cigna Commercial |
$3,090.60
|
| Rate for Payer: First Health Commercial |
$3,272.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,272.40
|
| Rate for Payer: GEHA Commercial |
$2,908.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,272.40
|
| Rate for Payer: Humana ChoiceCare |
$945.36
|
| Rate for Payer: Multiplan All |
$3,308.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,181.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,545.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,272.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,454.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,727.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,199.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$909.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,381.48
|
| Rate for Payer: Zelis Auto |
$1,454.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,818.00
|
|
|
IMPLT PATELLA STANDARD 8.5X34MM
|
Facility
|
IP
|
$3,636.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,454.40 |
| Max. Negotiated Rate |
$3,454.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,908.80
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cash Price |
$2,181.60
|
| Rate for Payer: Cigna Commercial |
$3,090.60
|
| Rate for Payer: First Health Commercial |
$3,272.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,272.40
|
| Rate for Payer: GEHA Commercial |
$2,545.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,272.40
|
| Rate for Payer: Multiplan All |
$3,308.76
|
| Rate for Payer: OMNI Networks Commercial |
$2,545.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,272.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,454.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,727.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,381.48
|
| Rate for Payer: Zelis Auto |
$1,454.40
|
|
|
IMPLT PATELLA SYMMETRIC SIZE27MM 8MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
|
IMPLT PATELLA SYMMETRIC SIZE27MM 8MM
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$889.20 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,778.40
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,556.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
|
|
IMPLT PATELLA SYMMETRIC SIZE29MM 8MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006188
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.75 |
| Max. Negotiated Rate |
$2,111.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cash Price |
$1,333.80
|
| Rate for Payer: Cigna Commercial |
$1,889.55
|
| Rate for Payer: First Health Commercial |
$2,000.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,000.70
|
| Rate for Payer: GEHA Commercial |
$1,778.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,000.70
|
| Rate for Payer: Humana ChoiceCare |
$577.98
|
| Rate for Payer: Multiplan All |
$2,022.93
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,333.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,556.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,000.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,111.85
|
| Rate for Payer: Three Rivers Provider Network All |
$1,667.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,956.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$555.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,067.39
|
| Rate for Payer: Zelis Auto |
$889.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,111.50
|
|
