|
IMPLT SLEEVE TIBIAL KNEE MRH
|
Facility
|
OP
|
$1,992.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.00 |
| Max. Negotiated Rate |
$1,892.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,195.20
|
| 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 |
$1,593.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,792.80
|
| Rate for Payer: Humana ChoiceCare |
$517.92
|
| Rate for Payer: Multiplan All |
$1,812.72
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,195.20
|
| 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: TriWest Veterans Administration/VAPC3 |
$1,752.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$498.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,852.56
|
| Rate for Payer: Zelis Auto |
$796.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$996.00
|
|
|
IMPLT SLEEVE TITANIUM MODULAR
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002286
|
|
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 TITANIUM MODULAR
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002286
|
|
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 SLING CURVED OBTRYX II
|
Facility
|
IP
|
$4,156.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7001779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.40 |
| Max. Negotiated Rate |
$3,948.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,324.80
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cigna Commercial |
$3,532.60
|
| Rate for Payer: First Health Commercial |
$3,740.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,740.40
|
| Rate for Payer: GEHA Commercial |
$2,909.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,740.40
|
| Rate for Payer: Multiplan All |
$3,781.96
|
| Rate for Payer: OMNI Networks Commercial |
$2,909.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,740.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,948.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,117.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,865.08
|
| Rate for Payer: Zelis Auto |
$1,662.40
|
|
|
IMPLT SLING CURVED OBTRYX II
|
Facility
|
OP
|
$4,156.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7001779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,039.00 |
| Max. Negotiated Rate |
$3,948.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cigna Commercial |
$3,532.60
|
| Rate for Payer: First Health Commercial |
$3,740.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,740.40
|
| Rate for Payer: GEHA Commercial |
$3,324.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,740.40
|
| Rate for Payer: Humana ChoiceCare |
$1,080.56
|
| Rate for Payer: Multiplan All |
$3,781.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,493.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,909.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,740.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,948.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,117.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,657.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,039.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,865.08
|
| Rate for Payer: Zelis Auto |
$1,662.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,078.00
|
|
|
IMPLT SLING HALO OBTRYX II
|
Facility
|
OP
|
$4,156.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7006141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,039.00 |
| Max. Negotiated Rate |
$3,948.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cigna Commercial |
$3,532.60
|
| Rate for Payer: First Health Commercial |
$3,740.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,740.40
|
| Rate for Payer: GEHA Commercial |
$3,324.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,740.40
|
| Rate for Payer: Humana ChoiceCare |
$1,080.56
|
| Rate for Payer: Multiplan All |
$3,781.96
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,493.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,909.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,740.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,948.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,117.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,657.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,039.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,865.08
|
| Rate for Payer: Zelis Auto |
$1,662.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,078.00
|
|
|
IMPLT SLING HALO OBTRYX II
|
Facility
|
IP
|
$4,156.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7006141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.40 |
| Max. Negotiated Rate |
$3,948.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,324.80
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cash Price |
$2,493.60
|
| Rate for Payer: Cigna Commercial |
$3,532.60
|
| Rate for Payer: First Health Commercial |
$3,740.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,740.40
|
| Rate for Payer: GEHA Commercial |
$2,909.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,740.40
|
| Rate for Payer: Multiplan All |
$3,781.96
|
| Rate for Payer: OMNI Networks Commercial |
$2,909.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,740.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,948.20
|
| Rate for Payer: Three Rivers Provider Network All |
$3,117.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,865.08
|
| Rate for Payer: Zelis Auto |
$1,662.40
|
|
|
IMPLT SLING INCISIONAL ALTIS
|
Facility
|
OP
|
$5,228.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7006625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,307.00 |
| Max. Negotiated Rate |
$4,966.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,136.80
|
| Rate for Payer: Cash Price |
$3,136.80
|
| Rate for Payer: Cash Price |
$3,136.80
|
| Rate for Payer: Cigna Commercial |
$4,443.80
|
| Rate for Payer: First Health Commercial |
$4,705.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,705.20
|
| Rate for Payer: GEHA Commercial |
$4,182.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,705.20
|
| Rate for Payer: Humana ChoiceCare |
$1,359.28
|
| Rate for Payer: Multiplan All |
$4,757.48
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,136.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,659.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,705.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,966.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,921.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,600.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,307.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,862.04
|
| Rate for Payer: Zelis Auto |
$2,091.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,614.00
|
|
|
IMPLT SLING INCISIONAL ALTIS
|
Facility
|
IP
|
$5,228.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7006625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,091.20 |
| Max. Negotiated Rate |
$4,966.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,182.40
|
| Rate for Payer: Cash Price |
$3,136.80
|
| Rate for Payer: Cash Price |
$3,136.80
|
| Rate for Payer: Cigna Commercial |
$4,443.80
|
| Rate for Payer: First Health Commercial |
$4,705.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,705.20
|
| Rate for Payer: GEHA Commercial |
$3,659.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,705.20
|
| Rate for Payer: Multiplan All |
$4,757.48
|
| Rate for Payer: OMNI Networks Commercial |
$3,659.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,705.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,966.60
|
| Rate for Payer: Three Rivers Provider Network All |
$3,921.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,862.04
|
| Rate for Payer: Zelis Auto |
$2,091.20
|
|
|
IMPLT SLING REPLIFORM 4X7CM
|
Facility
|
OP
|
$3,416.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
7002742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$854.00 |
| Max. Negotiated Rate |
$3,245.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,049.60
|
| Rate for Payer: Cash Price |
$2,049.60
|
| Rate for Payer: Cash Price |
$2,049.60
|
| Rate for Payer: Cigna Commercial |
$2,903.60
|
| Rate for Payer: First Health Commercial |
$3,074.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,074.40
|
| Rate for Payer: GEHA Commercial |
$2,732.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,074.40
|
| Rate for Payer: Humana ChoiceCare |
$888.16
|
| Rate for Payer: Multiplan All |
$3,108.56
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,049.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,391.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,074.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,245.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,562.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,006.08
|
| Rate for Payer: United Healthcare Managed Medicaid |
$854.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,176.88
|
| Rate for Payer: Zelis Auto |
$1,366.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,708.00
|
|
|
IMPLT SLING REPLIFORM 4X7CM
|
Facility
|
IP
|
$3,416.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
7002742
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,366.40 |
| Max. Negotiated Rate |
$3,245.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,732.80
|
| Rate for Payer: Cash Price |
$2,049.60
|
| Rate for Payer: Cash Price |
$2,049.60
|
| Rate for Payer: Cigna Commercial |
$2,903.60
|
| Rate for Payer: First Health Commercial |
$3,074.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,074.40
|
| Rate for Payer: GEHA Commercial |
$2,391.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,074.40
|
| Rate for Payer: Multiplan All |
$3,108.56
|
| Rate for Payer: OMNI Networks Commercial |
$2,391.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,074.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,245.20
|
| Rate for Payer: Three Rivers Provider Network All |
$2,562.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,176.88
|
| Rate for Payer: Zelis Auto |
$1,366.40
|
|
|
IMPLT SLING REPLIFORM 5X10CM
|
Facility
|
IP
|
$5,047.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
7002741
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,018.80 |
| Max. Negotiated Rate |
$4,794.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,037.60
|
| Rate for Payer: Cash Price |
$3,028.20
|
| Rate for Payer: Cash Price |
$3,028.20
|
| Rate for Payer: Cigna Commercial |
$4,289.95
|
| Rate for Payer: First Health Commercial |
$4,542.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,542.30
|
| Rate for Payer: GEHA Commercial |
$3,532.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,542.30
|
| Rate for Payer: Multiplan All |
$4,592.77
|
| Rate for Payer: OMNI Networks Commercial |
$3,532.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,542.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,794.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,785.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,693.71
|
| Rate for Payer: Zelis Auto |
$2,018.80
|
|
|
IMPLT SLING REPLIFORM 5X10CM
|
Facility
|
OP
|
$5,047.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
7002741
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,261.75 |
| Max. Negotiated Rate |
$4,794.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,028.20
|
| Rate for Payer: Cash Price |
$3,028.20
|
| Rate for Payer: Cash Price |
$3,028.20
|
| Rate for Payer: Cigna Commercial |
$4,289.95
|
| Rate for Payer: First Health Commercial |
$4,542.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,542.30
|
| Rate for Payer: GEHA Commercial |
$4,037.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,542.30
|
| Rate for Payer: Humana ChoiceCare |
$1,312.22
|
| Rate for Payer: Multiplan All |
$4,592.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,028.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,532.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,542.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,794.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,785.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,441.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,261.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,693.71
|
| Rate for Payer: Zelis Auto |
$2,018.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,523.50
|
|
|
IMPLT SLING SUPRAPUBIC LYNX
|
Facility
|
IP
|
$3,734.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7001780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,493.60 |
| Max. Negotiated Rate |
$3,547.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,987.20
|
| Rate for Payer: Cash Price |
$2,240.40
|
| Rate for Payer: Cash Price |
$2,240.40
|
| Rate for Payer: Cigna Commercial |
$3,173.90
|
| Rate for Payer: First Health Commercial |
$3,360.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,360.60
|
| Rate for Payer: GEHA Commercial |
$2,613.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,360.60
|
| Rate for Payer: Multiplan All |
$3,397.94
|
| Rate for Payer: OMNI Networks Commercial |
$2,613.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,360.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,547.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,800.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,472.62
|
| Rate for Payer: Zelis Auto |
$1,493.60
|
|
|
IMPLT SLING SUPRAPUBIC LYNX
|
Facility
|
OP
|
$3,734.00
|
|
|
Service Code
|
CPT C1771
|
| Hospital Charge Code |
7001780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.50 |
| Max. Negotiated Rate |
$3,547.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,240.40
|
| Rate for Payer: Cash Price |
$2,240.40
|
| Rate for Payer: Cash Price |
$2,240.40
|
| Rate for Payer: Cigna Commercial |
$3,173.90
|
| Rate for Payer: First Health Commercial |
$3,360.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,360.60
|
| Rate for Payer: GEHA Commercial |
$2,987.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,360.60
|
| Rate for Payer: Humana ChoiceCare |
$970.84
|
| Rate for Payer: Multiplan All |
$3,397.94
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,240.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,613.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,360.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,547.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,800.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,285.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$933.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,472.62
|
| Rate for Payer: Zelis Auto |
$1,493.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,867.00
|
|
|
IMPLT SORBAFIX 30
|
Facility
|
OP
|
$2,436.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002909
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$609.00 |
| Max. Negotiated Rate |
$2,314.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,461.60
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cigna Commercial |
$2,070.60
|
| Rate for Payer: First Health Commercial |
$2,192.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,192.40
|
| Rate for Payer: GEHA Commercial |
$1,948.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,192.40
|
| Rate for Payer: Humana ChoiceCare |
$633.36
|
| Rate for Payer: Multiplan All |
$2,216.76
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,461.60
|
| Rate for Payer: OMNI Networks Commercial |
$1,705.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,192.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,314.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,827.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,143.68
|
| Rate for Payer: United Healthcare Managed Medicaid |
$609.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,265.48
|
| Rate for Payer: Zelis Auto |
$974.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,218.00
|
|
|
IMPLT SORBAFIX 30
|
Facility
|
IP
|
$2,436.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
7002909
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$974.40 |
| Max. Negotiated Rate |
$2,314.20 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,948.80
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cigna Commercial |
$2,070.60
|
| Rate for Payer: First Health Commercial |
$2,192.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,192.40
|
| Rate for Payer: GEHA Commercial |
$1,705.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,192.40
|
| Rate for Payer: Multiplan All |
$2,216.76
|
| Rate for Payer: OMNI Networks Commercial |
$1,705.20
|
| Rate for Payer: One Health Plan PPO/POS |
$2,192.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,314.20
|
| Rate for Payer: Three Rivers Provider Network All |
$1,827.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,265.48
|
| Rate for Payer: Zelis Auto |
$974.40
|
|
|
IMPLT SPACER CEMENT DISTAL 8MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001592
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
|
IMPLT SPACER CEMENT DISTAL 8MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001592
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
IMPLT SPACER HUMERAL STEM SIZE 9MM
|
Facility
|
OP
|
$2,893.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001594
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$723.25 |
| Max. Negotiated Rate |
$2,748.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cigna Commercial |
$2,459.05
|
| Rate for Payer: First Health Commercial |
$2,603.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,603.70
|
| Rate for Payer: GEHA Commercial |
$2,314.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,603.70
|
| Rate for Payer: Humana ChoiceCare |
$752.18
|
| Rate for Payer: Multiplan All |
$2,632.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,735.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,025.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,603.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,748.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,169.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,545.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$723.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,690.49
|
| Rate for Payer: Zelis Auto |
$1,157.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,446.50
|
|
|
IMPLT SPACER HUMERAL STEM SIZE 9MM
|
Facility
|
IP
|
$2,893.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001594
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,157.20 |
| Max. Negotiated Rate |
$2,748.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,314.40
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cash Price |
$1,735.80
|
| Rate for Payer: Cigna Commercial |
$2,459.05
|
| Rate for Payer: First Health Commercial |
$2,603.70
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,603.70
|
| Rate for Payer: GEHA Commercial |
$2,025.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,603.70
|
| Rate for Payer: Multiplan All |
$2,632.63
|
| Rate for Payer: OMNI Networks Commercial |
$2,025.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,603.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,748.35
|
| Rate for Payer: Three Rivers Provider Network All |
$2,169.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,690.49
|
| Rate for Payer: Zelis Auto |
$1,157.20
|
|
|
IMPLT SPACER TENDON ROD HUNTER 24CMX4MM
|
Facility
|
IP
|
$4,918.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,967.20 |
| Max. Negotiated Rate |
$4,672.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,934.40
|
| Rate for Payer: Cash Price |
$2,950.80
|
| Rate for Payer: Cash Price |
$2,950.80
|
| Rate for Payer: Cigna Commercial |
$4,180.30
|
| Rate for Payer: First Health Commercial |
$4,426.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,426.20
|
| Rate for Payer: GEHA Commercial |
$3,442.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,426.20
|
| Rate for Payer: Multiplan All |
$4,475.38
|
| Rate for Payer: OMNI Networks Commercial |
$3,442.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,426.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,672.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,688.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,573.74
|
| Rate for Payer: Zelis Auto |
$1,967.20
|
|
|
IMPLT SPACER TENDON ROD HUNTER 24CMX4MM
|
Facility
|
OP
|
$4,918.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$4,672.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,950.80
|
| Rate for Payer: Cash Price |
$2,950.80
|
| Rate for Payer: Cash Price |
$2,950.80
|
| Rate for Payer: Cigna Commercial |
$4,180.30
|
| Rate for Payer: First Health Commercial |
$4,426.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,426.20
|
| Rate for Payer: GEHA Commercial |
$3,934.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,426.20
|
| Rate for Payer: Humana ChoiceCare |
$1,278.68
|
| Rate for Payer: Multiplan All |
$4,475.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,950.80
|
| Rate for Payer: OMNI Networks Commercial |
$3,442.60
|
| Rate for Payer: One Health Plan PPO/POS |
$4,426.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,672.10
|
| Rate for Payer: Three Rivers Provider Network All |
$3,688.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,327.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,229.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,573.74
|
| Rate for Payer: Zelis Auto |
$1,967.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,459.00
|
|
|
IMPLT SPACER UNIVERSAL DISTAL 9MM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$528.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$462.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
|
|
IMPLT SPACER UNIVERSAL DISTAL 9MM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001596
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$627.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$561.00
|
| Rate for Payer: First Health Commercial |
$594.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$594.00
|
| Rate for Payer: GEHA Commercial |
$528.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$594.00
|
| Rate for Payer: Humana ChoiceCare |
$171.60
|
| Rate for Payer: Multiplan All |
$600.60
|
| Rate for Payer: New Mexico Health Connections Medicare |
$396.00
|
| Rate for Payer: OMNI Networks Commercial |
$462.00
|
| Rate for Payer: One Health Plan PPO/POS |
$594.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$627.00
|
| Rate for Payer: Three Rivers Provider Network All |
$495.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$580.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$165.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$613.80
|
| Rate for Payer: Zelis Auto |
$264.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$330.00
|
|
