|
IMPLT PLATE LOCKING PROXIMAL TIBIAL
|
Facility
|
IP
|
$6,580.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,632.00 |
| Max. Negotiated Rate |
$6,251.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,264.00
|
| Rate for Payer: Cash Price |
$3,948.00
|
| Rate for Payer: Cash Price |
$3,948.00
|
| Rate for Payer: Cigna Commercial |
$5,593.00
|
| Rate for Payer: First Health Commercial |
$5,922.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,922.00
|
| Rate for Payer: GEHA Commercial |
$4,606.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,922.00
|
| Rate for Payer: Multiplan All |
$5,987.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,606.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,922.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,251.00
|
| Rate for Payer: Three Rivers Provider Network All |
$4,935.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,119.40
|
| Rate for Payer: Zelis Auto |
$2,632.00
|
|
|
IMPLT PLATE LOCKING PROXIMAL TIBIAL
|
Facility
|
OP
|
$6,580.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,645.00 |
| Max. Negotiated Rate |
$6,251.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,948.00
|
| Rate for Payer: Cash Price |
$3,948.00
|
| Rate for Payer: Cash Price |
$3,948.00
|
| Rate for Payer: Cigna Commercial |
$5,593.00
|
| Rate for Payer: First Health Commercial |
$5,922.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,922.00
|
| Rate for Payer: GEHA Commercial |
$5,264.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,922.00
|
| Rate for Payer: Humana ChoiceCare |
$1,710.80
|
| Rate for Payer: Multiplan All |
$5,987.80
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,948.00
|
| Rate for Payer: OMNI Networks Commercial |
$4,606.00
|
| Rate for Payer: One Health Plan PPO/POS |
$5,922.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,251.00
|
| Rate for Payer: Three Rivers Provider Network All |
$4,935.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,790.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,645.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,119.40
|
| Rate for Payer: Zelis Auto |
$2,632.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,290.00
|
|
|
IMPLT PLATE LOCKING STANDARD HD R 62MM
|
Facility
|
OP
|
$2,360.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$590.00 |
| Max. Negotiated Rate |
$2,242.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,416.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cigna Commercial |
$2,006.00
|
| Rate for Payer: First Health Commercial |
$2,124.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,124.00
|
| Rate for Payer: GEHA Commercial |
$1,888.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,124.00
|
| Rate for Payer: Humana ChoiceCare |
$613.60
|
| Rate for Payer: Multiplan All |
$2,147.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,416.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,652.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,124.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,242.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,770.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,076.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$590.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,194.80
|
| Rate for Payer: Zelis Auto |
$944.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,180.00
|
|
|
IMPLT PLATE LOCKING STANDARD HD R 62MM
|
Facility
|
IP
|
$2,360.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$944.00 |
| Max. Negotiated Rate |
$2,242.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,888.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cigna Commercial |
$2,006.00
|
| Rate for Payer: First Health Commercial |
$2,124.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,124.00
|
| Rate for Payer: GEHA Commercial |
$1,652.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,124.00
|
| Rate for Payer: Multiplan All |
$2,147.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,652.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,124.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,242.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,770.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,194.80
|
| Rate for Payer: Zelis Auto |
$944.00
|
|
|
IMPLT PLATE LOCKING TIBIAL 3.5MM 8 HOLE
|
Facility
|
IP
|
$5,310.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,124.00 |
| Max. Negotiated Rate |
$5,044.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,248.00
|
| Rate for Payer: Cash Price |
$3,186.00
|
| Rate for Payer: Cash Price |
$3,186.00
|
| Rate for Payer: Cigna Commercial |
$4,513.50
|
| Rate for Payer: First Health Commercial |
$4,779.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,779.00
|
| Rate for Payer: GEHA Commercial |
$3,717.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,779.00
|
| Rate for Payer: Multiplan All |
$4,832.10
|
| Rate for Payer: OMNI Networks Commercial |
$3,717.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,779.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,044.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,982.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,938.30
|
| Rate for Payer: Zelis Auto |
$2,124.00
|
|
|
IMPLT PLATE LOCKING TIBIAL 3.5MM 8 HOLE
|
Facility
|
OP
|
$5,310.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,327.50 |
| Max. Negotiated Rate |
$5,044.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,186.00
|
| Rate for Payer: Cash Price |
$3,186.00
|
| Rate for Payer: Cash Price |
$3,186.00
|
| Rate for Payer: Cigna Commercial |
$4,513.50
|
| Rate for Payer: First Health Commercial |
$4,779.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,779.00
|
| Rate for Payer: GEHA Commercial |
$4,248.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,779.00
|
| Rate for Payer: Humana ChoiceCare |
$1,380.60
|
| Rate for Payer: Multiplan All |
$4,832.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,186.00
|
| Rate for Payer: OMNI Networks Commercial |
$3,717.00
|
| Rate for Payer: One Health Plan PPO/POS |
$4,779.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,044.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,982.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,672.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,327.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,938.30
|
| Rate for Payer: Zelis Auto |
$2,124.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,655.00
|
|
|
IMPLT PLATE LOCKING TIBIAL HOLE 4 LEFT
|
Facility
|
OP
|
$5,996.00
|
|
|
Service Code
|
CPT C1716
|
| Hospital Charge Code |
70001820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$5,696.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$64.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,597.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$64.28
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$50.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$824.51
|
| Rate for Payer: Cash Price |
$3,597.60
|
| Rate for Payer: Cash Price |
$3,597.60
|
| Rate for Payer: Cash Price |
$3,597.60
|
| Rate for Payer: Cigna Commercial |
$5,096.60
|
| Rate for Payer: First Health Commercial |
$5,396.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,396.40
|
| Rate for Payer: GEHA Commercial |
$4,796.80
|
| Rate for Payer: GEHA Medicare |
$824.51
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,396.40
|
| Rate for Payer: Humana ChoiceCare |
$906.96
|
| Rate for Payer: Humana Medicare Advantage |
$824.51
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$1,385.18
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$51.96
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$824.51
|
| Rate for Payer: Multiplan All |
$5,456.36
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,401.67
|
| Rate for Payer: OMNI Networks Commercial |
$4,197.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,396.40
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$59.99
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$51.96
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$824.51
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,696.20
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$1,649.02
|
| Rate for Payer: Three Rivers Provider Network All |
$4,497.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$808.02
|
| Rate for Payer: United Healthcare Managed Medicaid |
$51.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$824.51
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,576.28
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$824.51
|
| Rate for Payer: Zelis Auto |
$2,398.40
|
| Rate for Payer: Zelis Medicare |
$700.83
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$989.41
|
|
|
IMPLT PLATE LOCKING TIBIAL HOLE 4 LEFT
|
Facility
|
IP
|
$5,996.00
|
|
|
Service Code
|
CPT C1716
|
| Hospital Charge Code |
70001820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,398.40 |
| Max. Negotiated Rate |
$5,696.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,796.80
|
| Rate for Payer: Cash Price |
$3,597.60
|
| Rate for Payer: Cash Price |
$3,597.60
|
| Rate for Payer: Cigna Commercial |
$5,096.60
|
| Rate for Payer: First Health Commercial |
$5,396.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,396.40
|
| Rate for Payer: GEHA Commercial |
$4,197.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,396.40
|
| Rate for Payer: Multiplan All |
$5,456.36
|
| Rate for Payer: OMNI Networks Commercial |
$4,197.20
|
| Rate for Payer: One Health Plan PPO/POS |
$5,396.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,696.20
|
| Rate for Payer: Three Rivers Provider Network All |
$4,497.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,576.28
|
| Rate for Payer: Zelis Auto |
$2,398.40
|
|
|
IMPLT PLATE,LOCKING TUBULAR 7 HOLE 3.5MM
|
Facility
|
IP
|
$1,068.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000412
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$427.20 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$854.40
|
| Rate for Payer: Cash Price |
$640.80
|
| Rate for Payer: Cash Price |
$640.80
|
| Rate for Payer: Cigna Commercial |
$907.80
|
| Rate for Payer: First Health Commercial |
$961.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$961.20
|
| Rate for Payer: GEHA Commercial |
$747.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$961.20
|
| Rate for Payer: Multiplan All |
$971.88
|
| Rate for Payer: OMNI Networks Commercial |
$747.60
|
| Rate for Payer: One Health Plan PPO/POS |
$961.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,014.60
|
| Rate for Payer: Three Rivers Provider Network All |
$801.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$993.24
|
| Rate for Payer: Zelis Auto |
$427.20
|
|
|
IMPLT PLATE,LOCKING TUBULAR 7 HOLE 3.5MM
|
Facility
|
OP
|
$1,068.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000412
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$267.00 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$640.80
|
| Rate for Payer: Cash Price |
$640.80
|
| Rate for Payer: Cash Price |
$640.80
|
| Rate for Payer: Cigna Commercial |
$907.80
|
| Rate for Payer: First Health Commercial |
$961.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$961.20
|
| Rate for Payer: GEHA Commercial |
$854.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$961.20
|
| Rate for Payer: Humana ChoiceCare |
$277.68
|
| Rate for Payer: Multiplan All |
$971.88
|
| Rate for Payer: New Mexico Health Connections Medicare |
$640.80
|
| Rate for Payer: OMNI Networks Commercial |
$747.60
|
| Rate for Payer: One Health Plan PPO/POS |
$961.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,014.60
|
| Rate for Payer: Three Rivers Provider Network All |
$801.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$939.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$267.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$993.24
|
| Rate for Payer: Zelis Auto |
$427.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$534.00
|
|
|
IMPLT PLATE LONG DORIAL
|
Facility
|
OP
|
$6,038.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,509.50 |
| Max. Negotiated Rate |
$5,736.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,622.80
|
| Rate for Payer: Cash Price |
$3,622.80
|
| Rate for Payer: Cash Price |
$3,622.80
|
| Rate for Payer: Cigna Commercial |
$5,132.30
|
| Rate for Payer: First Health Commercial |
$5,434.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,434.20
|
| Rate for Payer: GEHA Commercial |
$4,830.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,434.20
|
| Rate for Payer: Humana ChoiceCare |
$1,569.88
|
| Rate for Payer: Multiplan All |
$5,494.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,622.80
|
| Rate for Payer: OMNI Networks Commercial |
$4,226.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,434.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,736.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,528.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,313.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,509.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,615.34
|
| Rate for Payer: Zelis Auto |
$2,415.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,019.00
|
|
|
IMPLT PLATE LONG DORIAL
|
Facility
|
IP
|
$6,038.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000339
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,415.20 |
| Max. Negotiated Rate |
$5,736.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,830.40
|
| Rate for Payer: Cash Price |
$3,622.80
|
| Rate for Payer: Cash Price |
$3,622.80
|
| Rate for Payer: Cigna Commercial |
$5,132.30
|
| Rate for Payer: First Health Commercial |
$5,434.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,434.20
|
| Rate for Payer: GEHA Commercial |
$4,226.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,434.20
|
| Rate for Payer: Multiplan All |
$5,494.58
|
| Rate for Payer: OMNI Networks Commercial |
$4,226.60
|
| Rate for Payer: One Health Plan PPO/POS |
$5,434.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,736.10
|
| Rate for Payer: Three Rivers Provider Network All |
$4,528.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,615.34
|
| Rate for Payer: Zelis Auto |
$2,415.20
|
|
|
IMPLT PLATE LONG NARROW
|
Facility
|
IP
|
$3,276.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001195
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.40 |
| Max. Negotiated Rate |
$3,112.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,620.80
|
| Rate for Payer: Cash Price |
$1,965.60
|
| Rate for Payer: Cash Price |
$1,965.60
|
| Rate for Payer: Cigna Commercial |
$2,784.60
|
| Rate for Payer: First Health Commercial |
$2,948.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,948.40
|
| Rate for Payer: GEHA Commercial |
$2,293.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,948.40
|
| Rate for Payer: Multiplan All |
$2,981.16
|
| Rate for Payer: OMNI Networks Commercial |
$2,293.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,948.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,112.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,457.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,046.68
|
| Rate for Payer: Zelis Auto |
$1,310.40
|
|
|
IMPLT PLATE LONG NARROW
|
Facility
|
OP
|
$3,276.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001195
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$819.00 |
| Max. Negotiated Rate |
$3,112.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,965.60
|
| Rate for Payer: Cash Price |
$1,965.60
|
| Rate for Payer: Cash Price |
$1,965.60
|
| Rate for Payer: Cigna Commercial |
$2,784.60
|
| Rate for Payer: First Health Commercial |
$2,948.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,948.40
|
| Rate for Payer: GEHA Commercial |
$2,620.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,948.40
|
| Rate for Payer: Humana ChoiceCare |
$851.76
|
| Rate for Payer: Multiplan All |
$2,981.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,965.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,293.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,948.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,112.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,457.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,882.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$819.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,046.68
|
| Rate for Payer: Zelis Auto |
$1,310.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,638.00
|
|
|
IMPLT PLATE MAXILLOFACIAL
|
Facility
|
OP
|
$2,549.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$637.25 |
| Max. Negotiated Rate |
$2,421.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,529.40
|
| Rate for Payer: Cash Price |
$1,529.40
|
| Rate for Payer: Cash Price |
$1,529.40
|
| Rate for Payer: Cigna Commercial |
$2,166.65
|
| Rate for Payer: First Health Commercial |
$2,294.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,294.10
|
| Rate for Payer: GEHA Commercial |
$2,039.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,294.10
|
| Rate for Payer: Humana ChoiceCare |
$662.74
|
| Rate for Payer: Multiplan All |
$2,319.59
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,529.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,784.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,294.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,421.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,911.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,243.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$637.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,370.57
|
| Rate for Payer: Zelis Auto |
$1,019.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,274.50
|
|
|
IMPLT PLATE MAXILLOFACIAL
|
Facility
|
IP
|
$2,549.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001196
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,019.60 |
| Max. Negotiated Rate |
$2,421.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,039.20
|
| Rate for Payer: Cash Price |
$1,529.40
|
| Rate for Payer: Cash Price |
$1,529.40
|
| Rate for Payer: Cigna Commercial |
$2,166.65
|
| Rate for Payer: First Health Commercial |
$2,294.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,294.10
|
| Rate for Payer: GEHA Commercial |
$1,784.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,294.10
|
| Rate for Payer: Multiplan All |
$2,319.59
|
| Rate for Payer: OMNI Networks Commercial |
$1,784.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,294.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,421.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,911.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,370.57
|
| Rate for Payer: Zelis Auto |
$1,019.60
|
|
|
IMPLT PLATE MED DIST HUM LK 79MM
|
Facility
|
IP
|
$3,303.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,321.20 |
| Max. Negotiated Rate |
$3,137.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,642.40
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cigna Commercial |
$2,807.55
|
| Rate for Payer: First Health Commercial |
$2,972.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,972.70
|
| Rate for Payer: GEHA Commercial |
$2,312.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,972.70
|
| Rate for Payer: Multiplan All |
$3,005.73
|
| Rate for Payer: OMNI Networks Commercial |
$2,312.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,972.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,137.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,477.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,071.79
|
| Rate for Payer: Zelis Auto |
$1,321.20
|
|
|
IMPLT PLATE MED DIST HUM LK 79MM
|
Facility
|
OP
|
$3,303.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001197
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.75 |
| Max. Negotiated Rate |
$3,137.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cigna Commercial |
$2,807.55
|
| Rate for Payer: First Health Commercial |
$2,972.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,972.70
|
| Rate for Payer: GEHA Commercial |
$2,642.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,972.70
|
| Rate for Payer: Humana ChoiceCare |
$858.78
|
| Rate for Payer: Multiplan All |
$3,005.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,981.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,312.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,972.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,137.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,477.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,906.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$825.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,071.79
|
| Rate for Payer: Zelis Auto |
$1,321.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,651.50
|
|
|
IMPLT PLATE MED HUM LK 5H L 79MM
|
Facility
|
IP
|
$3,303.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001198
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,321.20 |
| Max. Negotiated Rate |
$3,137.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,642.40
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cigna Commercial |
$2,807.55
|
| Rate for Payer: First Health Commercial |
$2,972.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,972.70
|
| Rate for Payer: GEHA Commercial |
$2,312.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,972.70
|
| Rate for Payer: Multiplan All |
$3,005.73
|
| Rate for Payer: OMNI Networks Commercial |
$2,312.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,972.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,137.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,477.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,071.79
|
| Rate for Payer: Zelis Auto |
$1,321.20
|
|
|
IMPLT PLATE MED HUM LK 5H L 79MM
|
Facility
|
OP
|
$3,303.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001198
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.75 |
| Max. Negotiated Rate |
$3,137.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cash Price |
$1,981.80
|
| Rate for Payer: Cigna Commercial |
$2,807.55
|
| Rate for Payer: First Health Commercial |
$2,972.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,972.70
|
| Rate for Payer: GEHA Commercial |
$2,642.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,972.70
|
| Rate for Payer: Humana ChoiceCare |
$858.78
|
| Rate for Payer: Multiplan All |
$3,005.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,981.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,312.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,972.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,137.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2,477.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,906.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$825.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,071.79
|
| Rate for Payer: Zelis Auto |
$1,321.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,651.50
|
|
|
IMPLT PLATE MEDIUM 5 HOLE
|
Facility
|
OP
|
$2,629.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$657.25 |
| Max. Negotiated Rate |
$2,497.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,577.40
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$2,234.65
|
| Rate for Payer: First Health Commercial |
$2,366.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,366.10
|
| Rate for Payer: GEHA Commercial |
$2,103.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,366.10
|
| Rate for Payer: Humana ChoiceCare |
$683.54
|
| Rate for Payer: Multiplan All |
$2,392.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,577.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,840.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,366.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,497.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,971.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,313.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$657.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,444.97
|
| Rate for Payer: Zelis Auto |
$1,051.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,314.50
|
|
|
IMPLT PLATE MEDIUM 5 HOLE
|
Facility
|
IP
|
$2,629.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,051.60 |
| Max. Negotiated Rate |
$2,497.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,103.20
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cash Price |
$1,577.40
|
| Rate for Payer: Cigna Commercial |
$2,234.65
|
| Rate for Payer: First Health Commercial |
$2,366.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,366.10
|
| Rate for Payer: GEHA Commercial |
$1,840.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,366.10
|
| Rate for Payer: Multiplan All |
$2,392.39
|
| Rate for Payer: OMNI Networks Commercial |
$1,840.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,366.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,497.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,971.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,444.97
|
| Rate for Payer: Zelis Auto |
$1,051.60
|
|
|
IMPLT PLATE MEDIUM HOLE
|
Facility
|
OP
|
$2,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000340
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$2,470.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cigna Commercial |
$2,210.00
|
| Rate for Payer: First Health Commercial |
$2,340.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,340.00
|
| Rate for Payer: GEHA Commercial |
$2,080.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,340.00
|
| Rate for Payer: Humana ChoiceCare |
$676.00
|
| Rate for Payer: Multiplan All |
$2,366.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,560.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,820.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,340.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,470.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,950.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,288.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$650.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,418.00
|
| Rate for Payer: Zelis Auto |
$1,040.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,300.00
|
|
|
IMPLT PLATE MEDIUM HOLE
|
Facility
|
IP
|
$2,600.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7000340
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$2,470.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,080.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cigna Commercial |
$2,210.00
|
| Rate for Payer: First Health Commercial |
$2,340.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,340.00
|
| Rate for Payer: GEHA Commercial |
$1,820.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,340.00
|
| Rate for Payer: Multiplan All |
$2,366.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,820.00
|
| Rate for Payer: One Health Plan PPO/POS |
$2,340.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,470.00
|
| Rate for Payer: Three Rivers Provider Network All |
$1,950.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,418.00
|
| Rate for Payer: Zelis Auto |
$1,040.00
|
|
|
IMPLT PLATE MED STANDARD 4 HOLE
|
Facility
|
IP
|
$895.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001199
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$358.00 |
| Max. Negotiated Rate |
$850.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$716.00
|
| Rate for Payer: Cash Price |
$537.00
|
| Rate for Payer: Cash Price |
$537.00
|
| Rate for Payer: Cigna Commercial |
$760.75
|
| Rate for Payer: First Health Commercial |
$805.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$805.50
|
| Rate for Payer: GEHA Commercial |
$626.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$805.50
|
| Rate for Payer: Multiplan All |
$814.45
|
| Rate for Payer: OMNI Networks Commercial |
$626.50
|
| Rate for Payer: One Health Plan PPO/POS |
$805.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$850.25
|
| Rate for Payer: Three Rivers Provider Network All |
$671.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$832.35
|
| Rate for Payer: Zelis Auto |
$358.00
|
|
