|
IMPLT POST SCRW 4.5X35MM
|
Facility
|
OP
|
$635.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7002500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.75 |
| Max. Negotiated Rate |
$603.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$381.00
|
| Rate for Payer: Cash Price |
$381.00
|
| Rate for Payer: Cash Price |
$381.00
|
| Rate for Payer: Cigna Commercial |
$539.75
|
| Rate for Payer: First Health Commercial |
$571.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$571.50
|
| Rate for Payer: GEHA Commercial |
$508.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$571.50
|
| Rate for Payer: Humana ChoiceCare |
$165.10
|
| Rate for Payer: Multiplan All |
$577.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$381.00
|
| Rate for Payer: OMNI Networks Commercial |
$444.50
|
| Rate for Payer: One Health Plan PPO/POS |
$571.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$603.25
|
| Rate for Payer: Three Rivers Provider Network All |
$476.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$558.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$158.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$590.55
|
| Rate for Payer: Zelis Auto |
$254.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$317.50
|
|
|
IMPLT POWER PORT 8FR SILICONE
|
Facility
|
OP
|
$2,482.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$620.50 |
| Max. Negotiated Rate |
$2,357.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,489.20
|
| Rate for Payer: Cash Price |
$1,489.20
|
| Rate for Payer: Cash Price |
$1,489.20
|
| Rate for Payer: Cigna Commercial |
$2,109.70
|
| Rate for Payer: First Health Commercial |
$2,233.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,233.80
|
| Rate for Payer: GEHA Commercial |
$1,985.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,233.80
|
| Rate for Payer: Humana ChoiceCare |
$645.32
|
| Rate for Payer: Multiplan All |
$2,258.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,489.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,737.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,233.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,357.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,861.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,184.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$620.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,308.26
|
| Rate for Payer: Zelis Auto |
$992.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,241.00
|
|
|
IMPLT POWER PORT 8FR SILICONE
|
Facility
|
IP
|
$2,482.00
|
|
|
Service Code
|
CPT C1788
|
| Hospital Charge Code |
7002387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$992.80 |
| Max. Negotiated Rate |
$2,357.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,985.60
|
| Rate for Payer: Cash Price |
$1,489.20
|
| Rate for Payer: Cash Price |
$1,489.20
|
| Rate for Payer: Cigna Commercial |
$2,109.70
|
| Rate for Payer: First Health Commercial |
$2,233.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,233.80
|
| Rate for Payer: GEHA Commercial |
$1,737.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,233.80
|
| Rate for Payer: Multiplan All |
$2,258.62
|
| Rate for Payer: OMNI Networks Commercial |
$1,737.40
|
| Rate for Payer: One Health Plan PPO/POS |
$2,233.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,357.90
|
| Rate for Payer: Three Rivers Provider Network All |
$1,861.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,308.26
|
| Rate for Payer: Zelis Auto |
$992.80
|
|
|
IMPLT PRIMARY FEMORAL CEMENTED LEFT
|
Facility
|
IP
|
$12,209.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002123
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,883.60 |
| Max. Negotiated Rate |
$11,598.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,767.20
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cigna Commercial |
$10,377.65
|
| Rate for Payer: First Health Commercial |
$10,988.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,988.10
|
| Rate for Payer: GEHA Commercial |
$8,546.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,988.10
|
| Rate for Payer: Multiplan All |
$11,110.19
|
| Rate for Payer: OMNI Networks Commercial |
$8,546.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,988.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,598.55
|
| Rate for Payer: Three Rivers Provider Network All |
$9,156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,354.37
|
| Rate for Payer: Zelis Auto |
$4,883.60
|
|
|
IMPLT PRIMARY FEMORAL CEMENTED LEFT
|
Facility
|
OP
|
$12,209.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002123
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,052.25 |
| Max. Negotiated Rate |
$11,598.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cigna Commercial |
$10,377.65
|
| Rate for Payer: First Health Commercial |
$10,988.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,988.10
|
| Rate for Payer: GEHA Commercial |
$9,767.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,988.10
|
| Rate for Payer: Humana ChoiceCare |
$3,174.34
|
| Rate for Payer: Multiplan All |
$11,110.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,325.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,546.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,988.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,598.55
|
| Rate for Payer: Three Rivers Provider Network All |
$9,156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,743.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,052.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,354.37
|
| Rate for Payer: Zelis Auto |
$4,883.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,104.50
|
|
|
IMPLT PRIMARY FEMORAL LARGE RIGHT
|
Facility
|
IP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,666.00 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,332.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$8,165.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
|
|
IMPLT PRIMARY FEMORAL LARGE RIGHT
|
Facility
|
OP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,916.25 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$9,332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Humana ChoiceCare |
$3,032.90
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,999.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,265.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,916.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,832.50
|
|
|
IMPLT PRIMARY FEMORAL STANDARD LEFT
|
Facility
|
IP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,666.00 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,332.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$8,165.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
|
|
IMPLT PRIMARY FEMORAL STANDARD LEFT
|
Facility
|
OP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,916.25 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$9,332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Humana ChoiceCare |
$3,032.90
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,999.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,265.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,916.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,832.50
|
|
|
IMPLT PRIMARY FEMORAL STANDARD RIGHT
|
Facility
|
IP
|
$12,209.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,883.60 |
| Max. Negotiated Rate |
$11,598.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,767.20
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cigna Commercial |
$10,377.65
|
| Rate for Payer: First Health Commercial |
$10,988.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,988.10
|
| Rate for Payer: GEHA Commercial |
$8,546.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,988.10
|
| Rate for Payer: Multiplan All |
$11,110.19
|
| Rate for Payer: OMNI Networks Commercial |
$8,546.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,988.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,598.55
|
| Rate for Payer: Three Rivers Provider Network All |
$9,156.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,354.37
|
| Rate for Payer: Zelis Auto |
$4,883.60
|
|
|
IMPLT PRIMARY FEMORAL STANDARD RIGHT
|
Facility
|
IP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,666.00 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,332.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$8,165.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
|
|
IMPLT PRIMARY FEMORAL STANDARD RIGHT
|
Facility
|
OP
|
$12,209.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,052.25 |
| Max. Negotiated Rate |
$11,598.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cigna Commercial |
$10,377.65
|
| Rate for Payer: First Health Commercial |
$10,988.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,988.10
|
| Rate for Payer: GEHA Commercial |
$9,767.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,988.10
|
| Rate for Payer: Humana ChoiceCare |
$3,174.34
|
| Rate for Payer: Multiplan All |
$11,110.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,325.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,546.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,988.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,598.55
|
| Rate for Payer: Three Rivers Provider Network All |
$9,156.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,743.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,052.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,354.37
|
| Rate for Payer: Zelis Auto |
$4,883.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,104.50
|
|
|
IMPLT PRIMARY FEMORAL STANDARD RIGHT
|
Facility
|
OP
|
$11,665.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002269
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,916.25 |
| Max. Negotiated Rate |
$11,081.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cash Price |
$6,999.00
|
| Rate for Payer: Cigna Commercial |
$9,915.25
|
| Rate for Payer: First Health Commercial |
$10,498.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,498.50
|
| Rate for Payer: GEHA Commercial |
$9,332.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,498.50
|
| Rate for Payer: Humana ChoiceCare |
$3,032.90
|
| Rate for Payer: Multiplan All |
$10,615.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,999.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,165.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,498.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,081.75
|
| Rate for Payer: Three Rivers Provider Network All |
$8,748.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,265.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,916.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,848.45
|
| Rate for Payer: Zelis Auto |
$4,666.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,832.50
|
|
|
IMPLT PROBE TURBO SUP AMBIENT 90 DEGREE
|
Facility
|
OP
|
$1,078.00
|
|
|
Service Code
|
CPT C2618
|
| Hospital Charge Code |
7002450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$269.50 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$862.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Humana ChoiceCare |
$280.28
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: New Mexico Health Connections Medicare |
$646.80
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$948.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$269.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$539.00
|
|
|
IMPLT PROBE TURBO SUP AMBIENT 90 DEGREE
|
Facility
|
IP
|
$1,078.00
|
|
|
Service Code
|
CPT C2618
|
| Hospital Charge Code |
7002450
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$431.20 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$862.40
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Cigna Commercial |
$916.30
|
| Rate for Payer: First Health Commercial |
$970.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$970.20
|
| Rate for Payer: GEHA Commercial |
$754.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$970.20
|
| Rate for Payer: Multiplan All |
$980.98
|
| Rate for Payer: OMNI Networks Commercial |
$754.60
|
| Rate for Payer: One Health Plan PPO/POS |
$970.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,024.10
|
| Rate for Payer: Three Rivers Provider Network All |
$808.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,002.54
|
| Rate for Payer: Zelis Auto |
$431.20
|
|
|
IMPLT PROCLAIM XR5
|
Facility
|
IP
|
$61,646.00
|
|
|
Service Code
|
CPT C1778
|
| Hospital Charge Code |
7006663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24,658.40 |
| Max. Negotiated Rate |
$58,563.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$49,316.80
|
| Rate for Payer: Cash Price |
$36,987.60
|
| Rate for Payer: Cash Price |
$36,987.60
|
| Rate for Payer: Cigna Commercial |
$52,399.10
|
| Rate for Payer: First Health Commercial |
$55,481.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$55,481.40
|
| Rate for Payer: GEHA Commercial |
$43,152.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$55,481.40
|
| Rate for Payer: Multiplan All |
$56,097.86
|
| Rate for Payer: OMNI Networks Commercial |
$43,152.20
|
| Rate for Payer: One Health Plan PPO/POS |
$55,481.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$58,563.70
|
| Rate for Payer: Three Rivers Provider Network All |
$46,234.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$57,330.78
|
| Rate for Payer: Zelis Auto |
$24,658.40
|
|
|
IMPLT PROCLAIM XR5
|
Facility
|
OP
|
$61,646.00
|
|
|
Service Code
|
CPT C1778
|
| Hospital Charge Code |
7006663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,411.50 |
| Max. Negotiated Rate |
$58,563.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36,987.60
|
| Rate for Payer: Cash Price |
$36,987.60
|
| Rate for Payer: Cash Price |
$36,987.60
|
| Rate for Payer: Cigna Commercial |
$52,399.10
|
| Rate for Payer: First Health Commercial |
$55,481.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$55,481.40
|
| Rate for Payer: GEHA Commercial |
$49,316.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$55,481.40
|
| Rate for Payer: Humana ChoiceCare |
$16,027.96
|
| Rate for Payer: Multiplan All |
$56,097.86
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36,987.60
|
| Rate for Payer: OMNI Networks Commercial |
$43,152.20
|
| Rate for Payer: One Health Plan PPO/POS |
$55,481.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$58,563.70
|
| Rate for Payer: Three Rivers Provider Network All |
$46,234.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$54,248.48
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15,411.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$57,330.78
|
| Rate for Payer: Zelis Auto |
$24,658.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30,823.00
|
|
|
IMPLT PRODIGY MRI
|
Facility
|
OP
|
$61,338.00
|
|
|
Service Code
|
CPT C1778
|
| Hospital Charge Code |
7006664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,334.50 |
| Max. Negotiated Rate |
$58,271.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$36,802.80
|
| Rate for Payer: Cash Price |
$36,802.80
|
| Rate for Payer: Cash Price |
$36,802.80
|
| Rate for Payer: Cigna Commercial |
$52,137.30
|
| Rate for Payer: First Health Commercial |
$55,204.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$55,204.20
|
| Rate for Payer: GEHA Commercial |
$49,070.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$55,204.20
|
| Rate for Payer: Humana ChoiceCare |
$15,947.88
|
| Rate for Payer: Multiplan All |
$55,817.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$36,802.80
|
| Rate for Payer: OMNI Networks Commercial |
$42,936.60
|
| Rate for Payer: One Health Plan PPO/POS |
$55,204.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$58,271.10
|
| Rate for Payer: Three Rivers Provider Network All |
$46,003.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$53,977.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$15,334.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$57,044.34
|
| Rate for Payer: Zelis Auto |
$24,535.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$30,669.00
|
|
|
IMPLT PRODIGY MRI
|
Facility
|
IP
|
$61,338.00
|
|
|
Service Code
|
CPT C1778
|
| Hospital Charge Code |
7006664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24,535.20 |
| Max. Negotiated Rate |
$58,271.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$49,070.40
|
| Rate for Payer: Cash Price |
$36,802.80
|
| Rate for Payer: Cash Price |
$36,802.80
|
| Rate for Payer: Cigna Commercial |
$52,137.30
|
| Rate for Payer: First Health Commercial |
$55,204.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$55,204.20
|
| Rate for Payer: GEHA Commercial |
$42,936.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$55,204.20
|
| Rate for Payer: Multiplan All |
$55,817.58
|
| Rate for Payer: OMNI Networks Commercial |
$42,936.60
|
| Rate for Payer: One Health Plan PPO/POS |
$55,204.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$58,271.10
|
| Rate for Payer: Three Rivers Provider Network All |
$46,003.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$57,044.34
|
| Rate for Payer: Zelis Auto |
$24,535.20
|
|
|
IMPLT PROSTEP MICA 4X50MM
|
Facility
|
OP
|
$2,911.16
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.79 |
| Max. Negotiated Rate |
$2,765.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,746.70
|
| Rate for Payer: Cash Price |
$1,746.70
|
| Rate for Payer: Cash Price |
$1,746.70
|
| Rate for Payer: Cigna Commercial |
$2,474.49
|
| Rate for Payer: First Health Commercial |
$2,620.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,620.04
|
| Rate for Payer: GEHA Commercial |
$2,328.93
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,620.04
|
| Rate for Payer: Humana ChoiceCare |
$756.90
|
| Rate for Payer: Multiplan All |
$2,649.16
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,746.70
|
| Rate for Payer: OMNI Networks Commercial |
$2,037.81
|
| Rate for Payer: One Health Plan PPO/POS |
$2,620.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,765.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,183.37
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,561.82
|
| Rate for Payer: United Healthcare Managed Medicaid |
$727.79
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,707.38
|
| Rate for Payer: Zelis Auto |
$1,164.46
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,455.58
|
|
|
IMPLT PROSTEP MICA 4X50MM
|
Facility
|
IP
|
$2,911.16
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7009271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,164.46 |
| Max. Negotiated Rate |
$2,765.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,328.93
|
| Rate for Payer: Cash Price |
$1,746.70
|
| Rate for Payer: Cash Price |
$1,746.70
|
| Rate for Payer: Cigna Commercial |
$2,474.49
|
| Rate for Payer: First Health Commercial |
$2,620.04
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,620.04
|
| Rate for Payer: GEHA Commercial |
$2,037.81
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,620.04
|
| Rate for Payer: Multiplan All |
$2,649.16
|
| Rate for Payer: OMNI Networks Commercial |
$2,037.81
|
| Rate for Payer: One Health Plan PPO/POS |
$2,620.04
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,765.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,183.37
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,707.38
|
| Rate for Payer: Zelis Auto |
$1,164.46
|
|
|
IMPLT PROSTHESIS GOLDENBERG
|
Facility
|
OP
|
$989.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.25 |
| Max. Negotiated Rate |
$939.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$593.40
|
| Rate for Payer: Cash Price |
$593.40
|
| Rate for Payer: Cash Price |
$593.40
|
| Rate for Payer: Cigna Commercial |
$840.65
|
| Rate for Payer: First Health Commercial |
$890.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$890.10
|
| Rate for Payer: GEHA Commercial |
$791.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$890.10
|
| Rate for Payer: Humana ChoiceCare |
$257.14
|
| Rate for Payer: Multiplan All |
$899.99
|
| Rate for Payer: New Mexico Health Connections Medicare |
$593.40
|
| Rate for Payer: OMNI Networks Commercial |
$692.30
|
| Rate for Payer: One Health Plan PPO/POS |
$890.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$939.55
|
| Rate for Payer: Three Rivers Provider Network All |
$741.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$870.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$247.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$919.77
|
| Rate for Payer: Zelis Auto |
$395.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$494.50
|
|
|
IMPLT PROSTHESIS GOLDENBERG
|
Facility
|
IP
|
$989.00
|
|
|
Service Code
|
CPT L8613
|
| Hospital Charge Code |
7006506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$395.60 |
| Max. Negotiated Rate |
$939.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$791.20
|
| Rate for Payer: Cash Price |
$593.40
|
| Rate for Payer: Cash Price |
$593.40
|
| Rate for Payer: Cigna Commercial |
$840.65
|
| Rate for Payer: First Health Commercial |
$890.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$890.10
|
| Rate for Payer: GEHA Commercial |
$692.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$890.10
|
| Rate for Payer: Multiplan All |
$899.99
|
| Rate for Payer: OMNI Networks Commercial |
$692.30
|
| Rate for Payer: One Health Plan PPO/POS |
$890.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$939.55
|
| Rate for Payer: Three Rivers Provider Network All |
$741.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$919.77
|
| Rate for Payer: Zelis Auto |
$395.60
|
|
|
IMPLT PROSTHESIS GOLDENBERG CAP
|
Facility
|
OP
|
$2,109.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$527.25 |
| Max. Negotiated Rate |
$2,003.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,265.40
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cigna Commercial |
$1,792.65
|
| Rate for Payer: First Health Commercial |
$1,898.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,898.10
|
| Rate for Payer: GEHA Commercial |
$1,687.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,898.10
|
| Rate for Payer: Humana ChoiceCare |
$548.34
|
| Rate for Payer: Multiplan All |
$1,919.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,265.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,476.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,898.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,003.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,581.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,855.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$527.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,961.37
|
| Rate for Payer: Zelis Auto |
$843.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,054.50
|
|
|
IMPLT PROSTHESIS GOLDENBERG CAP
|
Facility
|
IP
|
$2,109.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$843.60 |
| Max. Negotiated Rate |
$2,003.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,687.20
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cigna Commercial |
$1,792.65
|
| Rate for Payer: First Health Commercial |
$1,898.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,898.10
|
| Rate for Payer: GEHA Commercial |
$1,476.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,898.10
|
| Rate for Payer: Multiplan All |
$1,919.19
|
| Rate for Payer: OMNI Networks Commercial |
$1,476.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,898.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,003.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,581.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,961.37
|
| Rate for Payer: Zelis Auto |
$843.60
|
|
