|
IMPLT PURAPLY 8X16
|
Facility
|
OP
|
$39,737.00
|
|
|
Service Code
|
CPT Q4196
|
| Hospital Charge Code |
7003179
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$37,750.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$23,842.20
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$153.42
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$121.54
|
| Rate for Payer: Cash Price |
$23,842.20
|
| Rate for Payer: Cash Price |
$23,842.20
|
| Rate for Payer: Cash Price |
$23,842.20
|
| Rate for Payer: Cigna Commercial |
$33,776.45
|
| Rate for Payer: First Health Commercial |
$35,763.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$35,763.30
|
| Rate for Payer: GEHA Commercial |
$111.13
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$35,763.30
|
| Rate for Payer: Humana ChoiceCare |
$10,331.62
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$124.01
|
| Rate for Payer: Multiplan All |
$36,160.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$23,842.20
|
| Rate for Payer: OMNI Networks Commercial |
$27,815.90
|
| Rate for Payer: One Health Plan PPO/POS |
$35,763.30
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$143.19
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$124.01
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$37,750.15
|
| Rate for Payer: Three Rivers Provider Network All |
$29,802.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$34,968.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$124.01
|
| Rate for Payer: United Payors & United Providers UP&UP |
$36,955.41
|
| Rate for Payer: Zelis Auto |
$15,894.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19,868.50
|
|
|
IMPLT PURAPLY XT 2X2
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$65.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 2X2
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$77.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Humana ChoiceCare |
$24.44
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.40
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$47.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 2X4
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$77.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Humana ChoiceCare |
$24.44
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.40
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$47.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 2X4
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$65.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 5X5
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$65.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 5X5
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$77.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Humana ChoiceCare |
$24.44
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.40
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$47.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 6X9
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$77.77
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Humana ChoiceCare |
$24.44
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: New Mexico Health Connections Medicare |
$56.40
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$82.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$23.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$47.00
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PURAPLY XT 6X9
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT Q4197
|
| Hospital Charge Code |
1999247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$79.90
|
| Rate for Payer: First Health Commercial |
$84.60
|
| Rate for Payer: First Health Workers Compensation |
$36.29
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$84.60
|
| Rate for Payer: GEHA Commercial |
$65.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$84.60
|
| Rate for Payer: Multiplan All |
$85.54
|
| Rate for Payer: OMNI Networks Commercial |
$65.80
|
| Rate for Payer: One Health Plan PPO/POS |
$84.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$89.30
|
| Rate for Payer: Three Rivers Provider Network All |
$70.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$87.42
|
| Rate for Payer: Zelis Auto |
$37.60
|
| Rate for Payer: Zelis Worker's Compensation |
$25.66
|
|
|
IMPLT PUSHER KNOT FAST FIX ULTRA
|
Facility
|
OP
|
$619.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001237
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$588.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$371.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cigna Commercial |
$526.15
|
| Rate for Payer: First Health Commercial |
$557.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$557.10
|
| Rate for Payer: GEHA Commercial |
$495.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$557.10
|
| Rate for Payer: Humana ChoiceCare |
$160.94
|
| Rate for Payer: Multiplan All |
$563.29
|
| Rate for Payer: New Mexico Health Connections Medicare |
$371.40
|
| Rate for Payer: OMNI Networks Commercial |
$433.30
|
| Rate for Payer: One Health Plan PPO/POS |
$557.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$588.05
|
| Rate for Payer: Three Rivers Provider Network All |
$464.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$544.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$154.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$575.67
|
| Rate for Payer: Zelis Auto |
$247.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$309.50
|
|
|
IMPLT PUSHER KNOT FAST FIX ULTRA
|
Facility
|
IP
|
$619.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001237
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.60 |
| Max. Negotiated Rate |
$588.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$495.20
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cigna Commercial |
$526.15
|
| Rate for Payer: First Health Commercial |
$557.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$557.10
|
| Rate for Payer: GEHA Commercial |
$433.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$557.10
|
| Rate for Payer: Multiplan All |
$563.29
|
| Rate for Payer: OMNI Networks Commercial |
$433.30
|
| Rate for Payer: One Health Plan PPO/POS |
$557.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$588.05
|
| Rate for Payer: Three Rivers Provider Network All |
$464.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$575.67
|
| Rate for Payer: Zelis Auto |
$247.60
|
|
|
IMPLT PUSHLOCK BIOCOMPOSITE 4.5X28MM
|
Facility
|
IP
|
$2,567.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,026.80 |
| Max. Negotiated Rate |
$2,438.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,053.60
|
| Rate for Payer: Cash Price |
$1,540.20
|
| Rate for Payer: Cash Price |
$1,540.20
|
| Rate for Payer: Cigna Commercial |
$2,181.95
|
| Rate for Payer: First Health Commercial |
$2,310.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,310.30
|
| Rate for Payer: GEHA Commercial |
$1,796.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,310.30
|
| Rate for Payer: Multiplan All |
$2,335.97
|
| Rate for Payer: OMNI Networks Commercial |
$1,796.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,310.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,438.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,925.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,387.31
|
| Rate for Payer: Zelis Auto |
$1,026.80
|
|
|
IMPLT PUSHLOCK BIOCOMPOSITE 4.5X28MM
|
Facility
|
OP
|
$2,567.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003037
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$641.75 |
| Max. Negotiated Rate |
$2,438.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,540.20
|
| Rate for Payer: Cash Price |
$1,540.20
|
| Rate for Payer: Cash Price |
$1,540.20
|
| Rate for Payer: Cigna Commercial |
$2,181.95
|
| Rate for Payer: First Health Commercial |
$2,310.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,310.30
|
| Rate for Payer: GEHA Commercial |
$2,053.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,310.30
|
| Rate for Payer: Humana ChoiceCare |
$667.42
|
| Rate for Payer: Multiplan All |
$2,335.97
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,540.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,796.90
|
| Rate for Payer: One Health Plan PPO/POS |
$2,310.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,438.65
|
| Rate for Payer: Three Rivers Provider Network All |
$1,925.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,258.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$641.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,387.31
|
| Rate for Payer: Zelis Auto |
$1,026.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,283.50
|
|
|
IMPLT QUICK ANCHOR MICRO DEPUY
|
Facility
|
OP
|
$2,137.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$534.25 |
| Max. Negotiated Rate |
$2,030.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,282.20
|
| Rate for Payer: Cash Price |
$1,282.20
|
| Rate for Payer: Cash Price |
$1,282.20
|
| Rate for Payer: Cigna Commercial |
$1,816.45
|
| Rate for Payer: First Health Commercial |
$1,923.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,923.30
|
| Rate for Payer: GEHA Commercial |
$1,709.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,923.30
|
| Rate for Payer: Humana ChoiceCare |
$555.62
|
| Rate for Payer: Multiplan All |
$1,944.67
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,282.20
|
| Rate for Payer: OMNI Networks Commercial |
$1,495.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,923.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,030.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,602.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,880.56
|
| Rate for Payer: United Healthcare Managed Medicaid |
$534.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,987.41
|
| Rate for Payer: Zelis Auto |
$854.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,068.50
|
|
|
IMPLT QUICK ANCHOR MICRO DEPUY
|
Facility
|
IP
|
$2,137.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$854.80 |
| Max. Negotiated Rate |
$2,030.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,709.60
|
| Rate for Payer: Cash Price |
$1,282.20
|
| Rate for Payer: Cash Price |
$1,282.20
|
| Rate for Payer: Cigna Commercial |
$1,816.45
|
| Rate for Payer: First Health Commercial |
$1,923.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,923.30
|
| Rate for Payer: GEHA Commercial |
$1,495.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,923.30
|
| Rate for Payer: Multiplan All |
$1,944.67
|
| Rate for Payer: OMNI Networks Commercial |
$1,495.90
|
| Rate for Payer: One Health Plan PPO/POS |
$1,923.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,030.15
|
| Rate for Payer: Three Rivers Provider Network All |
$1,602.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,987.41
|
| Rate for Payer: Zelis Auto |
$854.80
|
|
|
IMPLT RADIAL WRIST RIGHT LARGE
|
Facility
|
OP
|
$18,233.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,558.25 |
| Max. Negotiated Rate |
$17,321.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,939.80
|
| Rate for Payer: Cash Price |
$10,939.80
|
| Rate for Payer: Cash Price |
$10,939.80
|
| Rate for Payer: Cigna Commercial |
$15,498.05
|
| Rate for Payer: First Health Commercial |
$16,409.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16,409.70
|
| Rate for Payer: GEHA Commercial |
$14,586.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16,409.70
|
| Rate for Payer: Humana ChoiceCare |
$4,740.58
|
| Rate for Payer: Multiplan All |
$16,592.03
|
| Rate for Payer: New Mexico Health Connections Medicare |
$10,939.80
|
| Rate for Payer: OMNI Networks Commercial |
$12,763.10
|
| Rate for Payer: One Health Plan PPO/POS |
$16,409.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17,321.35
|
| Rate for Payer: Three Rivers Provider Network All |
$13,674.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$16,045.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4,558.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,956.69
|
| Rate for Payer: Zelis Auto |
$7,293.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$9,116.50
|
|
|
IMPLT RADIAL WRIST RIGHT LARGE
|
Facility
|
IP
|
$18,233.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7006556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,293.20 |
| Max. Negotiated Rate |
$17,321.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$14,586.40
|
| Rate for Payer: Cash Price |
$10,939.80
|
| Rate for Payer: Cash Price |
$10,939.80
|
| Rate for Payer: Cigna Commercial |
$15,498.05
|
| Rate for Payer: First Health Commercial |
$16,409.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$16,409.70
|
| Rate for Payer: GEHA Commercial |
$12,763.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$16,409.70
|
| Rate for Payer: Multiplan All |
$16,592.03
|
| Rate for Payer: OMNI Networks Commercial |
$12,763.10
|
| Rate for Payer: One Health Plan PPO/POS |
$16,409.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$17,321.35
|
| Rate for Payer: Three Rivers Provider Network All |
$13,674.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$16,956.69
|
| Rate for Payer: Zelis Auto |
$7,293.20
|
|
|
IMPLT REGENETEN LARGE
|
Facility
|
OP
|
$8,310.00
|
|
|
Service Code
|
CPT C1763
|
| Hospital Charge Code |
7002934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,077.50 |
| Max. Negotiated Rate |
$7,894.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cigna Commercial |
$7,063.50
|
| Rate for Payer: First Health Commercial |
$7,479.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,479.00
|
| Rate for Payer: GEHA Commercial |
$6,648.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,479.00
|
| Rate for Payer: Humana ChoiceCare |
$2,160.60
|
| Rate for Payer: Multiplan All |
$7,562.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,986.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,817.00
|
| Rate for Payer: One Health Plan PPO/POS |
$7,479.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,894.50
|
| Rate for Payer: Three Rivers Provider Network All |
$6,232.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,312.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,077.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,728.30
|
| Rate for Payer: Zelis Auto |
$3,324.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,155.00
|
|
|
IMPLT REGENETEN LARGE
|
Facility
|
IP
|
$8,310.00
|
|
|
Service Code
|
CPT C1763
|
| Hospital Charge Code |
7002934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,324.00 |
| Max. Negotiated Rate |
$7,894.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,648.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cigna Commercial |
$7,063.50
|
| Rate for Payer: First Health Commercial |
$7,479.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,479.00
|
| Rate for Payer: GEHA Commercial |
$5,817.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,479.00
|
| Rate for Payer: Multiplan All |
$7,562.10
|
| Rate for Payer: OMNI Networks Commercial |
$5,817.00
|
| Rate for Payer: One Health Plan PPO/POS |
$7,479.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,894.50
|
| Rate for Payer: Three Rivers Provider Network All |
$6,232.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,728.30
|
| Rate for Payer: Zelis Auto |
$3,324.00
|
|
|
IMPLT REGENETEN MEDIUM
|
Facility
|
OP
|
$8,310.00
|
|
|
Service Code
|
CPT C1763
|
| Hospital Charge Code |
7003009
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,077.50 |
| Max. Negotiated Rate |
$7,894.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cigna Commercial |
$7,063.50
|
| Rate for Payer: First Health Commercial |
$7,479.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,479.00
|
| Rate for Payer: GEHA Commercial |
$6,648.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,479.00
|
| Rate for Payer: Humana ChoiceCare |
$2,160.60
|
| Rate for Payer: Multiplan All |
$7,562.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,986.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,817.00
|
| Rate for Payer: One Health Plan PPO/POS |
$7,479.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,894.50
|
| Rate for Payer: Three Rivers Provider Network All |
$6,232.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,312.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,077.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,728.30
|
| Rate for Payer: Zelis Auto |
$3,324.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,155.00
|
|
|
IMPLT REGENETEN MEDIUM
|
Facility
|
IP
|
$8,310.00
|
|
|
Service Code
|
CPT C1763
|
| Hospital Charge Code |
7003009
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,324.00 |
| Max. Negotiated Rate |
$7,894.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,648.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cash Price |
$4,986.00
|
| Rate for Payer: Cigna Commercial |
$7,063.50
|
| Rate for Payer: First Health Commercial |
$7,479.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,479.00
|
| Rate for Payer: GEHA Commercial |
$5,817.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,479.00
|
| Rate for Payer: Multiplan All |
$7,562.10
|
| Rate for Payer: OMNI Networks Commercial |
$5,817.00
|
| Rate for Payer: One Health Plan PPO/POS |
$7,479.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,894.50
|
| Rate for Payer: Three Rivers Provider Network All |
$6,232.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,728.30
|
| Rate for Payer: Zelis Auto |
$3,324.00
|
|
|
IMPLT REGENKIT -THT
|
Facility
|
IP
|
$1,853.00
|
|
|
Service Code
|
CPT C9355
|
| Hospital Charge Code |
7002774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$741.20 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,482.40
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$1,575.05
|
| Rate for Payer: First Health Commercial |
$1,667.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,667.70
|
| Rate for Payer: GEHA Commercial |
$1,297.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,667.70
|
| Rate for Payer: Multiplan All |
$1,686.23
|
| Rate for Payer: OMNI Networks Commercial |
$1,297.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,667.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,760.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,389.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,723.29
|
| Rate for Payer: Zelis Auto |
$741.20
|
|
|
IMPLT REGENKIT -THT
|
Facility
|
OP
|
$1,853.00
|
|
|
Service Code
|
CPT C9355
|
| Hospital Charge Code |
7002774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$463.25 |
| Max. Negotiated Rate |
$1,760.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,111.80
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Cigna Commercial |
$1,575.05
|
| Rate for Payer: First Health Commercial |
$1,667.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,667.70
|
| Rate for Payer: GEHA Commercial |
$1,482.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,667.70
|
| Rate for Payer: Humana ChoiceCare |
$481.78
|
| Rate for Payer: Multiplan All |
$1,686.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,111.80
|
| Rate for Payer: OMNI Networks Commercial |
$1,297.10
|
| Rate for Payer: One Health Plan PPO/POS |
$1,667.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,760.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,389.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,630.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$463.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,723.29
|
| Rate for Payer: Zelis Auto |
$741.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$926.50
|
|
|
IMPLT RESERVOIR 65ML PC/IZ
|
Facility
|
OP
|
$8,771.25
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,192.81 |
| Max. Negotiated Rate |
$8,332.69 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,262.75
|
| Rate for Payer: Cash Price |
$5,262.75
|
| Rate for Payer: Cash Price |
$5,262.75
|
| Rate for Payer: Cigna Commercial |
$7,455.56
|
| Rate for Payer: First Health Commercial |
$7,894.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,894.12
|
| Rate for Payer: GEHA Commercial |
$7,017.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,894.12
|
| Rate for Payer: Humana ChoiceCare |
$2,280.53
|
| Rate for Payer: Multiplan All |
$7,981.84
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,262.75
|
| Rate for Payer: OMNI Networks Commercial |
$6,139.88
|
| Rate for Payer: One Health Plan PPO/POS |
$7,894.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,332.69
|
| Rate for Payer: Three Rivers Provider Network All |
$6,578.44
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,718.70
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,192.81
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,157.26
|
| Rate for Payer: Zelis Auto |
$3,508.50
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,385.62
|
|
|
IMPLT RESERVOIR 65ML PC/IZ
|
Facility
|
IP
|
$8,771.25
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002390
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.50 |
| Max. Negotiated Rate |
$8,332.69 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,017.00
|
| Rate for Payer: Cash Price |
$5,262.75
|
| Rate for Payer: Cash Price |
$5,262.75
|
| Rate for Payer: Cigna Commercial |
$7,455.56
|
| Rate for Payer: First Health Commercial |
$7,894.12
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,894.12
|
| Rate for Payer: GEHA Commercial |
$6,139.88
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,894.12
|
| Rate for Payer: Multiplan All |
$7,981.84
|
| Rate for Payer: OMNI Networks Commercial |
$6,139.88
|
| Rate for Payer: One Health Plan PPO/POS |
$7,894.12
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,332.69
|
| Rate for Payer: Three Rivers Provider Network All |
$6,578.44
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,157.26
|
| Rate for Payer: Zelis Auto |
$3,508.50
|
|
