|
IMPLT SHELL LINER BIPOLAR 50MM
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$42.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Humana ChoiceCare |
$13.78
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: New Mexico Health Connections Medicare |
$31.80
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$46.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$13.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$26.50
|
|
|
IMPLT SHELL LINER BIPOLAR 50MM
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$42.40
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$45.05
|
| Rate for Payer: First Health Commercial |
$47.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$47.70
|
| Rate for Payer: GEHA Commercial |
$37.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$47.70
|
| Rate for Payer: Multiplan All |
$48.23
|
| Rate for Payer: OMNI Networks Commercial |
$37.10
|
| Rate for Payer: One Health Plan PPO/POS |
$47.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$50.35
|
| Rate for Payer: Three Rivers Provider Network All |
$39.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$49.29
|
| Rate for Payer: Zelis Auto |
$21.20
|
|
|
IMPLT SILASTIC BIG TOE SZ.0
|
Facility
|
OP
|
$4,022.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,005.50 |
| Max. Negotiated Rate |
$3,820.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,413.20
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cigna Commercial |
$3,418.70
|
| Rate for Payer: First Health Commercial |
$3,619.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,619.80
|
| Rate for Payer: GEHA Commercial |
$3,217.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,619.80
|
| Rate for Payer: Humana ChoiceCare |
$1,045.72
|
| Rate for Payer: Multiplan All |
$3,660.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,413.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,815.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,619.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,820.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,016.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,539.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,005.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,740.46
|
| Rate for Payer: Zelis Auto |
$1,608.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,011.00
|
|
|
IMPLT SILASTIC BIG TOE SZ.0
|
Facility
|
IP
|
$4,022.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7001871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,608.80 |
| Max. Negotiated Rate |
$3,820.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,217.60
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cash Price |
$2,413.20
|
| Rate for Payer: Cigna Commercial |
$3,418.70
|
| Rate for Payer: First Health Commercial |
$3,619.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,619.80
|
| Rate for Payer: GEHA Commercial |
$2,815.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,619.80
|
| Rate for Payer: Multiplan All |
$3,660.02
|
| Rate for Payer: OMNI Networks Commercial |
$2,815.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,619.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,820.90
|
| Rate for Payer: Three Rivers Provider Network All |
$3,016.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,740.46
|
| Rate for Payer: Zelis Auto |
$1,608.80
|
|
|
IMPLT SILASTIC BIG TOE SZ 1
|
Facility
|
OP
|
$3,782.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$945.50 |
| Max. Negotiated Rate |
$3,592.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,269.20
|
| Rate for Payer: Cash Price |
$2,269.20
|
| Rate for Payer: Cash Price |
$2,269.20
|
| Rate for Payer: Cigna Commercial |
$3,214.70
|
| Rate for Payer: First Health Commercial |
$3,403.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,403.80
|
| Rate for Payer: GEHA Commercial |
$3,025.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,403.80
|
| Rate for Payer: Humana ChoiceCare |
$983.32
|
| Rate for Payer: Multiplan All |
$3,441.62
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,269.20
|
| Rate for Payer: OMNI Networks Commercial |
$2,647.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,403.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,592.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,836.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,328.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$945.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,517.26
|
| Rate for Payer: Zelis Auto |
$1,512.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,891.00
|
|
|
IMPLT SILASTIC BIG TOE SZ 1
|
Facility
|
IP
|
$3,782.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.80 |
| Max. Negotiated Rate |
$3,592.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,025.60
|
| Rate for Payer: Cash Price |
$2,269.20
|
| Rate for Payer: Cash Price |
$2,269.20
|
| Rate for Payer: Cigna Commercial |
$3,214.70
|
| Rate for Payer: First Health Commercial |
$3,403.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,403.80
|
| Rate for Payer: GEHA Commercial |
$2,647.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,403.80
|
| Rate for Payer: Multiplan All |
$3,441.62
|
| Rate for Payer: OMNI Networks Commercial |
$2,647.40
|
| Rate for Payer: One Health Plan PPO/POS |
$3,403.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,592.90
|
| Rate for Payer: Three Rivers Provider Network All |
$2,836.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,517.26
|
| Rate for Payer: Zelis Auto |
$1,512.80
|
|
|
IMPLT SKYLA 13.5MG SYSTEM IUD
|
Facility
|
IP
|
$3,179.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,271.60 |
| Max. Negotiated Rate |
$3,020.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,543.20
|
| Rate for Payer: Cash Price |
$1,907.40
|
| Rate for Payer: Cash Price |
$1,907.40
|
| Rate for Payer: Cigna Commercial |
$2,702.15
|
| Rate for Payer: First Health Commercial |
$2,861.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,861.10
|
| Rate for Payer: GEHA Commercial |
$2,225.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,861.10
|
| Rate for Payer: Multiplan All |
$2,892.89
|
| Rate for Payer: OMNI Networks Commercial |
$2,225.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,861.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,020.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,384.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,956.47
|
| Rate for Payer: Zelis Auto |
$1,271.60
|
|
|
IMPLT SKYLA 13.5MG SYSTEM IUD
|
Facility
|
OP
|
$3,179.00
|
|
|
Service Code
|
CPT C2617
|
| Hospital Charge Code |
7006626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$3,020.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,907.40
|
| Rate for Payer: Cash Price |
$1,907.40
|
| Rate for Payer: Cash Price |
$1,907.40
|
| Rate for Payer: Cigna Commercial |
$2,702.15
|
| Rate for Payer: First Health Commercial |
$2,861.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,861.10
|
| Rate for Payer: GEHA Commercial |
$2,543.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,861.10
|
| Rate for Payer: Humana ChoiceCare |
$826.54
|
| Rate for Payer: Multiplan All |
$2,892.89
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,907.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,225.30
|
| Rate for Payer: One Health Plan PPO/POS |
$2,861.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,020.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,384.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,797.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$794.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,956.47
|
| Rate for Payer: Zelis Auto |
$1,271.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,589.50
|
|
|
IMPLT SLEEVE ADJUSTABLE NECK STD V40
|
Facility
|
IP
|
$832.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006578
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$332.80 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$665.60
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$582.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
|
|
IMPLT SLEEVE ADJUSTABLE NECK STD V40
|
Facility
|
OP
|
$832.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006578
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$665.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Humana ChoiceCare |
$216.32
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$499.20
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$732.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$416.00
|
|
|
IMPLT SLEEVE ADJUSTMENT NECK OFFSET -4MM
|
Facility
|
IP
|
$832.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$332.80 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$665.60
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$582.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
|
|
IMPLT SLEEVE ADJUSTMENT NECK OFFSET -4MM
|
Facility
|
OP
|
$832.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$790.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$707.20
|
| Rate for Payer: First Health Commercial |
$748.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$748.80
|
| Rate for Payer: GEHA Commercial |
$665.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$748.80
|
| Rate for Payer: Humana ChoiceCare |
$216.32
|
| Rate for Payer: Multiplan All |
$757.12
|
| Rate for Payer: New Mexico Health Connections Medicare |
$499.20
|
| Rate for Payer: OMNI Networks Commercial |
$582.40
|
| Rate for Payer: One Health Plan PPO/POS |
$748.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$790.40
|
| Rate for Payer: Three Rivers Provider Network All |
$624.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$732.16
|
| Rate for Payer: United Healthcare Managed Medicaid |
$208.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$773.76
|
| Rate for Payer: Zelis Auto |
$332.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$416.00
|
|
|
IMPLT SLEEVE FRACTURE SHOULDER
|
Facility
|
IP
|
$1,529.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$611.60 |
| Max. Negotiated Rate |
$1,452.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,223.20
|
| Rate for Payer: Cash Price |
$917.40
|
| Rate for Payer: Cash Price |
$917.40
|
| Rate for Payer: Cigna Commercial |
$1,299.65
|
| Rate for Payer: First Health Commercial |
$1,376.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,376.10
|
| Rate for Payer: GEHA Commercial |
$1,070.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,376.10
|
| Rate for Payer: Multiplan All |
$1,391.39
|
| Rate for Payer: OMNI Networks Commercial |
$1,070.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,376.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,452.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,146.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,421.97
|
| Rate for Payer: Zelis Auto |
$611.60
|
|
|
IMPLT SLEEVE FRACTURE SHOULDER
|
Facility
|
OP
|
$1,529.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$382.25 |
| Max. Negotiated Rate |
$1,452.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$917.40
|
| Rate for Payer: Cash Price |
$917.40
|
| Rate for Payer: Cash Price |
$917.40
|
| Rate for Payer: Cigna Commercial |
$1,299.65
|
| Rate for Payer: First Health Commercial |
$1,376.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,376.10
|
| Rate for Payer: GEHA Commercial |
$1,223.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,376.10
|
| Rate for Payer: Humana ChoiceCare |
$397.54
|
| Rate for Payer: Multiplan All |
$1,391.39
|
| Rate for Payer: New Mexico Health Connections Medicare |
$917.40
|
| Rate for Payer: OMNI Networks Commercial |
$1,070.30
|
| Rate for Payer: One Health Plan PPO/POS |
$1,376.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,452.55
|
| Rate for Payer: Three Rivers Provider Network All |
$1,146.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,345.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$382.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,421.97
|
| Rate for Payer: Zelis Auto |
$611.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$764.50
|
|
|
IMPLT SLEEVE HEAD TITANIUM MODULAR
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$267.75
|
| Rate for Payer: First Health Commercial |
$283.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$283.50
|
| Rate for Payer: GEHA Commercial |
$252.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$283.50
|
| Rate for Payer: Humana ChoiceCare |
$81.90
|
| Rate for Payer: Multiplan All |
$286.65
|
| Rate for Payer: New Mexico Health Connections Medicare |
$189.00
|
| Rate for Payer: OMNI Networks Commercial |
$220.50
|
| Rate for Payer: One Health Plan PPO/POS |
$283.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$299.25
|
| Rate for Payer: Three Rivers Provider Network All |
$236.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$277.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$78.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$292.95
|
| Rate for Payer: Zelis Auto |
$126.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$157.50
|
|
|
IMPLT SLEEVE HEAD TITANIUM MODULAR
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$252.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$267.75
|
| Rate for Payer: First Health Commercial |
$283.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$283.50
|
| Rate for Payer: GEHA Commercial |
$220.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$283.50
|
| Rate for Payer: Multiplan All |
$286.65
|
| Rate for Payer: OMNI Networks Commercial |
$220.50
|
| Rate for Payer: One Health Plan PPO/POS |
$283.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$299.25
|
| Rate for Payer: Three Rivers Provider Network All |
$236.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$292.95
|
| Rate for Payer: Zelis Auto |
$126.00
|
|
|
IMPLT SLEEVE NECK +0 OFFSET C-TAPER
|
Facility
|
OP
|
$1,070.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$1,016.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$642.00
|
| Rate for Payer: Cash Price |
$642.00
|
| Rate for Payer: Cash Price |
$642.00
|
| Rate for Payer: Cigna Commercial |
$909.50
|
| Rate for Payer: First Health Commercial |
$963.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$963.00
|
| Rate for Payer: GEHA Commercial |
$856.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$963.00
|
| Rate for Payer: Humana ChoiceCare |
$278.20
|
| Rate for Payer: Multiplan All |
$973.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$642.00
|
| Rate for Payer: OMNI Networks Commercial |
$749.00
|
| Rate for Payer: One Health Plan PPO/POS |
$963.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,016.50
|
| Rate for Payer: Three Rivers Provider Network All |
$802.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$941.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$267.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$995.10
|
| Rate for Payer: Zelis Auto |
$428.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$535.00
|
|
|
IMPLT SLEEVE NECK +0 OFFSET C-TAPER
|
Facility
|
IP
|
$1,070.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$428.00 |
| Max. Negotiated Rate |
$1,016.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$856.00
|
| Rate for Payer: Cash Price |
$642.00
|
| Rate for Payer: Cash Price |
$642.00
|
| Rate for Payer: Cigna Commercial |
$909.50
|
| Rate for Payer: First Health Commercial |
$963.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$963.00
|
| Rate for Payer: GEHA Commercial |
$749.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$963.00
|
| Rate for Payer: Multiplan All |
$973.70
|
| Rate for Payer: OMNI Networks Commercial |
$749.00
|
| Rate for Payer: One Health Plan PPO/POS |
$963.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,016.50
|
| Rate for Payer: Three Rivers Provider Network All |
$802.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$995.10
|
| Rate for Payer: Zelis Auto |
$428.00
|
|
|
IMPLT SLEEVE POSITIONING FRACTURE
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002567
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$412.50 |
| Max. Negotiated Rate |
$1,567.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$990.00
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,402.50
|
| Rate for Payer: First Health Commercial |
$1,485.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,485.00
|
| Rate for Payer: GEHA Commercial |
$1,320.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,485.00
|
| Rate for Payer: Humana ChoiceCare |
$429.00
|
| Rate for Payer: Multiplan All |
$1,501.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$990.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,155.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,485.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,567.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,237.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,452.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$412.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,534.50
|
| Rate for Payer: Zelis Auto |
$660.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$825.00
|
|
|
IMPLT SLEEVE POSITIONING FRACTURE
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002567
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.00 |
| Max. Negotiated Rate |
$1,567.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,320.00
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,402.50
|
| Rate for Payer: First Health Commercial |
$1,485.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,485.00
|
| Rate for Payer: GEHA Commercial |
$1,155.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,485.00
|
| Rate for Payer: Multiplan All |
$1,501.50
|
| Rate for Payer: OMNI Networks Commercial |
$1,155.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,485.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,567.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,237.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,534.50
|
| Rate for Payer: Zelis Auto |
$660.00
|
|
|
IMPLT SLEEVE PROXIMAL SPA
|
Facility
|
IP
|
$6,292.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,516.80 |
| Max. Negotiated Rate |
$5,977.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,033.60
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$5,348.20
|
| Rate for Payer: First Health Commercial |
$5,662.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,662.80
|
| Rate for Payer: GEHA Commercial |
$4,404.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,662.80
|
| Rate for Payer: Multiplan All |
$5,725.72
|
| Rate for Payer: OMNI Networks Commercial |
$4,404.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,662.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,977.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,719.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,851.56
|
| Rate for Payer: Zelis Auto |
$2,516.80
|
|
|
IMPLT SLEEVE PROXIMAL SPA
|
Facility
|
OP
|
$6,292.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002575
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,573.00 |
| Max. Negotiated Rate |
$5,977.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cash Price |
$3,775.20
|
| Rate for Payer: Cigna Commercial |
$5,348.20
|
| Rate for Payer: First Health Commercial |
$5,662.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,662.80
|
| Rate for Payer: GEHA Commercial |
$5,033.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,662.80
|
| Rate for Payer: Humana ChoiceCare |
$1,635.92
|
| Rate for Payer: Multiplan All |
$5,725.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,775.20
|
| Rate for Payer: OMNI Networks Commercial |
$4,404.40
|
| Rate for Payer: One Health Plan PPO/POS |
$5,662.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,977.40
|
| Rate for Payer: Three Rivers Provider Network All |
$4,719.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,536.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,573.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,851.56
|
| Rate for Payer: Zelis Auto |
$2,516.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,146.00
|
|
|
IMPLT SLEEVE TAPERED UNIPOLAR 12/14
|
Facility
|
OP
|
$477.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$453.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$286.20
|
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Cigna Commercial |
$405.45
|
| Rate for Payer: First Health Commercial |
$429.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$429.30
|
| Rate for Payer: GEHA Commercial |
$381.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$429.30
|
| Rate for Payer: Humana ChoiceCare |
$124.02
|
| Rate for Payer: Multiplan All |
$434.07
|
| Rate for Payer: New Mexico Health Connections Medicare |
$286.20
|
| Rate for Payer: OMNI Networks Commercial |
$333.90
|
| Rate for Payer: One Health Plan PPO/POS |
$429.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$453.15
|
| Rate for Payer: Three Rivers Provider Network All |
$357.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$419.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$119.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$443.61
|
| Rate for Payer: Zelis Auto |
$190.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$238.50
|
|
|
IMPLT SLEEVE TAPERED UNIPOLAR 12/14
|
Facility
|
IP
|
$477.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$190.80 |
| Max. Negotiated Rate |
$453.15 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$381.60
|
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Cash Price |
$286.20
|
| Rate for Payer: Cigna Commercial |
$405.45
|
| Rate for Payer: First Health Commercial |
$429.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$429.30
|
| Rate for Payer: GEHA Commercial |
$333.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$429.30
|
| Rate for Payer: Multiplan All |
$434.07
|
| Rate for Payer: OMNI Networks Commercial |
$333.90
|
| Rate for Payer: One Health Plan PPO/POS |
$429.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$453.15
|
| Rate for Payer: Three Rivers Provider Network All |
$357.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$443.61
|
| Rate for Payer: Zelis Auto |
$190.80
|
|
|
IMPLT SLEEVE TIBIAL KNEE MRH
|
Facility
|
IP
|
$1,992.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$796.80 |
| Max. Negotiated Rate |
$1,892.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,593.60
|
| Rate for Payer: Cash Price |
$1,195.20
|
| Rate for Payer: Cash Price |
$1,195.20
|
| Rate for Payer: Cigna Commercial |
$1,693.20
|
| Rate for Payer: First Health Commercial |
$1,792.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,792.80
|
| Rate for Payer: GEHA Commercial |
$1,394.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,792.80
|
| Rate for Payer: Multiplan All |
$1,812.72
|
| Rate for Payer: OMNI Networks Commercial |
$1,394.40
|
| Rate for Payer: One Health Plan PPO/POS |
$1,792.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,892.40
|
| Rate for Payer: Three Rivers Provider Network All |
$1,494.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,852.56
|
| Rate for Payer: Zelis Auto |
$796.80
|
|
