|
IMPLT SHELL HEMISPHERICAL SIZE 54MM
|
Facility
|
OP
|
$9,310.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003314
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,327.50 |
| Max. Negotiated Rate |
$8,844.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,586.00
|
| Rate for Payer: Cash Price |
$5,586.00
|
| Rate for Payer: Cash Price |
$5,586.00
|
| Rate for Payer: Cigna Commercial |
$7,913.50
|
| Rate for Payer: First Health Commercial |
$8,379.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,379.00
|
| Rate for Payer: GEHA Commercial |
$7,448.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,379.00
|
| Rate for Payer: Humana ChoiceCare |
$2,420.60
|
| Rate for Payer: Multiplan All |
$8,472.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,586.00
|
| Rate for Payer: OMNI Networks Commercial |
$6,517.00
|
| Rate for Payer: One Health Plan PPO/POS |
$8,379.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,844.50
|
| Rate for Payer: Three Rivers Provider Network All |
$6,982.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,192.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,327.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,658.30
|
| Rate for Payer: Zelis Auto |
$3,724.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,655.00
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 56MM
|
Facility
|
IP
|
$8,505.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008010
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,402.00 |
| Max. Negotiated Rate |
$8,079.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,804.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cigna Commercial |
$7,229.25
|
| Rate for Payer: First Health Commercial |
$7,654.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,654.50
|
| Rate for Payer: GEHA Commercial |
$5,953.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,654.50
|
| Rate for Payer: Multiplan All |
$7,739.55
|
| Rate for Payer: OMNI Networks Commercial |
$5,953.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,654.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,079.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,378.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,909.65
|
| Rate for Payer: Zelis Auto |
$3,402.00
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 56MM
|
Facility
|
OP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,129.50 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Humana ChoiceCare |
$1,174.68
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,710.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,975.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,259.00
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 56MM
|
Facility
|
IP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.20 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,614.40
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,162.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 56MM
|
Facility
|
OP
|
$8,505.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008010
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.25 |
| Max. Negotiated Rate |
$8,079.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cigna Commercial |
$7,229.25
|
| Rate for Payer: First Health Commercial |
$7,654.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,654.50
|
| Rate for Payer: GEHA Commercial |
$6,804.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,654.50
|
| Rate for Payer: Humana ChoiceCare |
$2,211.30
|
| Rate for Payer: Multiplan All |
$7,739.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,103.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,953.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,654.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,079.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,378.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,484.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,126.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,909.65
|
| Rate for Payer: Zelis Auto |
$3,402.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,252.50
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 60MM
|
Facility
|
OP
|
$8,505.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,126.25 |
| Max. Negotiated Rate |
$8,079.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cigna Commercial |
$7,229.25
|
| Rate for Payer: First Health Commercial |
$7,654.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,654.50
|
| Rate for Payer: GEHA Commercial |
$6,804.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,654.50
|
| Rate for Payer: Humana ChoiceCare |
$2,211.30
|
| Rate for Payer: Multiplan All |
$7,739.55
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,103.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,953.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,654.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,079.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,378.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,484.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,126.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,909.65
|
| Rate for Payer: Zelis Auto |
$3,402.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,252.50
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 60MM
|
Facility
|
IP
|
$8,505.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,402.00 |
| Max. Negotiated Rate |
$8,079.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,804.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cash Price |
$5,103.00
|
| Rate for Payer: Cigna Commercial |
$7,229.25
|
| Rate for Payer: First Health Commercial |
$7,654.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,654.50
|
| Rate for Payer: GEHA Commercial |
$5,953.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,654.50
|
| Rate for Payer: Multiplan All |
$7,739.55
|
| Rate for Payer: OMNI Networks Commercial |
$5,953.50
|
| Rate for Payer: One Health Plan PPO/POS |
$7,654.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,079.75
|
| Rate for Payer: Three Rivers Provider Network All |
$6,378.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,909.65
|
| Rate for Payer: Zelis Auto |
$3,402.00
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 62MM
|
Facility
|
OP
|
$8,681.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,170.25 |
| Max. Negotiated Rate |
$8,246.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,208.60
|
| Rate for Payer: Cash Price |
$5,208.60
|
| Rate for Payer: Cash Price |
$5,208.60
|
| Rate for Payer: Cigna Commercial |
$7,378.85
|
| Rate for Payer: First Health Commercial |
$7,812.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,812.90
|
| Rate for Payer: GEHA Commercial |
$6,944.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,812.90
|
| Rate for Payer: Humana ChoiceCare |
$2,257.06
|
| Rate for Payer: Multiplan All |
$7,899.71
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,208.60
|
| Rate for Payer: OMNI Networks Commercial |
$6,076.70
|
| Rate for Payer: One Health Plan PPO/POS |
$7,812.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,246.95
|
| Rate for Payer: Three Rivers Provider Network All |
$6,510.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,639.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,170.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,073.33
|
| Rate for Payer: Zelis Auto |
$3,472.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,340.50
|
|
|
IMPLT SHELL HEMISPHERICAL SIZE 62MM
|
Facility
|
IP
|
$8,681.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.40 |
| Max. Negotiated Rate |
$8,246.95 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,944.80
|
| Rate for Payer: Cash Price |
$5,208.60
|
| Rate for Payer: Cash Price |
$5,208.60
|
| Rate for Payer: Cigna Commercial |
$7,378.85
|
| Rate for Payer: First Health Commercial |
$7,812.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,812.90
|
| Rate for Payer: GEHA Commercial |
$6,076.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,812.90
|
| Rate for Payer: Multiplan All |
$7,899.71
|
| Rate for Payer: OMNI Networks Commercial |
$6,076.70
|
| Rate for Payer: One Health Plan PPO/POS |
$7,812.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,246.95
|
| Rate for Payer: Three Rivers Provider Network All |
$6,510.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,073.33
|
| Rate for Payer: Zelis Auto |
$3,472.40
|
|
|
IMPLT SHELL HOLE CLUSTER 50MM SIZE
|
Facility
|
OP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002136
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,129.50 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Humana ChoiceCare |
$1,174.68
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,710.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,975.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,259.00
|
|
|
IMPLT SHELL HOLE CLUSTER 50MM SIZE
|
Facility
|
IP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002136
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.20 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,614.40
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,162.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI 54MM
|
Facility
|
IP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.20 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,614.40
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,162.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI 54MM
|
Facility
|
OP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,129.50 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Humana ChoiceCare |
$1,174.68
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,710.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,975.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,259.00
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI 58MM
|
Facility
|
OP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,129.50 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Humana ChoiceCare |
$1,174.68
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,710.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,975.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,259.00
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI 58MM
|
Facility
|
IP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.20 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,614.40
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,162.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI SIZE 60
|
Facility
|
OP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,129.50 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,614.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Humana ChoiceCare |
$1,174.68
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,710.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,975.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,129.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,259.00
|
|
|
IMPLT SHELL HOLE CLUSTER HEMI SIZE 60
|
Facility
|
IP
|
$4,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002508
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.20 |
| Max. Negotiated Rate |
$4,292.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,614.40
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cash Price |
$2,710.80
|
| Rate for Payer: Cigna Commercial |
$3,840.30
|
| Rate for Payer: First Health Commercial |
$4,066.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,066.20
|
| Rate for Payer: GEHA Commercial |
$3,162.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,066.20
|
| Rate for Payer: Multiplan All |
$4,111.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,162.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,066.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,292.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,388.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,201.74
|
| Rate for Payer: Zelis Auto |
$1,807.20
|
|
|
IMPLT SHELL HOLE CLUSTER HEMISPHERICAL
|
Facility
|
OP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006145
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: First Health Workers Compensation |
$1,881.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,897.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Humana ChoiceCare |
$1,266.72
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,923.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,287.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,218.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,436.00
|
| Rate for Payer: Zelis Worker's Compensation |
$1,330.06
|
|
|
IMPLT SHELL HOLE CLUSTER HEMISPHERICAL
|
Facility
|
IP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006145
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,330.06 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: First Health Workers Compensation |
$1,881.08
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
| Rate for Payer: Zelis Worker's Compensation |
$1,330.06
|
|
|
IMPLT SHELL HOLE CLUSTER SIZE 64MM
|
Facility
|
OP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,897.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Humana ChoiceCare |
$1,266.72
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,923.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,287.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,218.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,436.00
|
|
|
IMPLT SHELL HOLE CLUSTER SIZE 64MM
|
Facility
|
IP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,948.80 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,897.60
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
|
|
IMPLT SHELL HOLE THREE 56MM ACETABULAR
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002139
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.00 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,680.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,345.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
|
|
IMPLT SHELL HOLE THREE 56MM ACETABULAR
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002139
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.50 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,680.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Humana ChoiceCare |
$871.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,010.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,948.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$837.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,675.00
|
|
|
IMPLT SHELL LINER 3 HOLE 52MM
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.00 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,680.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,345.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
|
|
IMPLT SHELL LINER 3 HOLE 52MM
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002280
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.50 |
| Max. Negotiated Rate |
$3,182.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$2,847.50
|
| Rate for Payer: First Health Commercial |
$3,015.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,015.00
|
| Rate for Payer: GEHA Commercial |
$2,680.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,015.00
|
| Rate for Payer: Humana ChoiceCare |
$871.00
|
| Rate for Payer: Multiplan All |
$3,048.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,010.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,345.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,015.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,182.50
|
| Rate for Payer: Three Rivers Provider Network All |
$2,512.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,948.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$837.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,115.50
|
| Rate for Payer: Zelis Auto |
$1,340.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,675.00
|
|
