|
IMPLT SYSTEM HIP MOD REST 19MM +10 V40
|
Facility
|
OP
|
$11,699.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002816
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,924.75 |
| Max. Negotiated Rate |
$11,114.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,019.40
|
| Rate for Payer: Cash Price |
$7,019.40
|
| Rate for Payer: Cash Price |
$7,019.40
|
| Rate for Payer: Cigna Commercial |
$9,944.15
|
| Rate for Payer: First Health Commercial |
$10,529.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,529.10
|
| Rate for Payer: GEHA Commercial |
$9,359.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,529.10
|
| Rate for Payer: Humana ChoiceCare |
$3,041.74
|
| Rate for Payer: Multiplan All |
$10,646.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,019.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,189.30
|
| Rate for Payer: One Health Plan PPO/POS |
$10,529.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,114.05
|
| Rate for Payer: Three Rivers Provider Network All |
$8,774.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,295.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,924.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,880.07
|
| Rate for Payer: Zelis Auto |
$4,679.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,849.50
|
|
|
IMPLT SYSTEM HIP MODULAR
|
Facility
|
IP
|
$9,038.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002171
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,615.20 |
| Max. Negotiated Rate |
$8,586.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,230.40
|
| Rate for Payer: Cash Price |
$5,422.80
|
| Rate for Payer: Cash Price |
$5,422.80
|
| Rate for Payer: Cigna Commercial |
$7,682.30
|
| Rate for Payer: First Health Commercial |
$8,134.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,134.20
|
| Rate for Payer: GEHA Commercial |
$6,326.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,134.20
|
| Rate for Payer: Multiplan All |
$8,224.58
|
| Rate for Payer: OMNI Networks Commercial |
$6,326.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,134.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,586.10
|
| Rate for Payer: Three Rivers Provider Network All |
$6,778.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,405.34
|
| Rate for Payer: Zelis Auto |
$3,615.20
|
|
|
IMPLT SYSTEM HIP MODULAR
|
Facility
|
OP
|
$9,038.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002171
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,259.50 |
| Max. Negotiated Rate |
$8,586.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,422.80
|
| Rate for Payer: Cash Price |
$5,422.80
|
| Rate for Payer: Cash Price |
$5,422.80
|
| Rate for Payer: Cigna Commercial |
$7,682.30
|
| Rate for Payer: First Health Commercial |
$8,134.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,134.20
|
| Rate for Payer: GEHA Commercial |
$7,230.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,134.20
|
| Rate for Payer: Humana ChoiceCare |
$2,349.88
|
| Rate for Payer: Multiplan All |
$8,224.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,422.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,326.60
|
| Rate for Payer: One Health Plan PPO/POS |
$8,134.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,586.10
|
| Rate for Payer: Three Rivers Provider Network All |
$6,778.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,953.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,259.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,405.34
|
| Rate for Payer: Zelis Auto |
$3,615.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,519.00
|
|
|
IMPLT SYSTEM HIP MODULAR 155X23MM
|
Facility
|
IP
|
$8,598.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,439.20 |
| Max. Negotiated Rate |
$8,168.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,878.40
|
| Rate for Payer: Cash Price |
$5,158.80
|
| Rate for Payer: Cash Price |
$5,158.80
|
| Rate for Payer: Cigna Commercial |
$7,308.30
|
| Rate for Payer: First Health Commercial |
$7,738.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,738.20
|
| Rate for Payer: GEHA Commercial |
$6,018.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,738.20
|
| Rate for Payer: Multiplan All |
$7,824.18
|
| Rate for Payer: OMNI Networks Commercial |
$6,018.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,738.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,168.10
|
| Rate for Payer: Three Rivers Provider Network All |
$6,448.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,996.14
|
| Rate for Payer: Zelis Auto |
$3,439.20
|
|
|
IMPLT SYSTEM HIP MODULAR 155X23MM
|
Facility
|
IP
|
$10,507.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006457
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,203.12 |
| Max. Negotiated Rate |
$9,982.41 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,406.24
|
| Rate for Payer: Cash Price |
$6,304.68
|
| Rate for Payer: Cash Price |
$6,304.68
|
| Rate for Payer: Cigna Commercial |
$8,931.63
|
| Rate for Payer: First Health Commercial |
$9,457.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,457.02
|
| Rate for Payer: GEHA Commercial |
$7,355.46
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,457.02
|
| Rate for Payer: Multiplan All |
$9,562.10
|
| Rate for Payer: OMNI Networks Commercial |
$7,355.46
|
| Rate for Payer: One Health Plan PPO/POS |
$9,457.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,982.41
|
| Rate for Payer: Three Rivers Provider Network All |
$7,880.85
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,772.25
|
| Rate for Payer: Zelis Auto |
$4,203.12
|
|
|
IMPLT SYSTEM HIP MODULAR 155X23MM
|
Facility
|
OP
|
$10,507.80
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006457
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,626.95 |
| Max. Negotiated Rate |
$9,982.41 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,304.68
|
| Rate for Payer: Cash Price |
$6,304.68
|
| Rate for Payer: Cash Price |
$6,304.68
|
| Rate for Payer: Cigna Commercial |
$8,931.63
|
| Rate for Payer: First Health Commercial |
$9,457.02
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,457.02
|
| Rate for Payer: GEHA Commercial |
$8,406.24
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,457.02
|
| Rate for Payer: Humana ChoiceCare |
$2,732.03
|
| Rate for Payer: Multiplan All |
$9,562.10
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,304.68
|
| Rate for Payer: OMNI Networks Commercial |
$7,355.46
|
| Rate for Payer: One Health Plan PPO/POS |
$9,457.02
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,982.41
|
| Rate for Payer: Three Rivers Provider Network All |
$7,880.85
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$9,246.86
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,626.95
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,772.25
|
| Rate for Payer: Zelis Auto |
$4,203.12
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,253.90
|
|
|
IMPLT SYSTEM HIP MODULAR 155X23MM
|
Facility
|
OP
|
$8,598.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,149.50 |
| Max. Negotiated Rate |
$8,168.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,158.80
|
| Rate for Payer: Cash Price |
$5,158.80
|
| Rate for Payer: Cash Price |
$5,158.80
|
| Rate for Payer: Cigna Commercial |
$7,308.30
|
| Rate for Payer: First Health Commercial |
$7,738.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7,738.20
|
| Rate for Payer: GEHA Commercial |
$6,878.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7,738.20
|
| Rate for Payer: Humana ChoiceCare |
$2,235.48
|
| Rate for Payer: Multiplan All |
$7,824.18
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,158.80
|
| Rate for Payer: OMNI Networks Commercial |
$6,018.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7,738.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,168.10
|
| Rate for Payer: Three Rivers Provider Network All |
$6,448.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,566.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,149.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7,996.14
|
| Rate for Payer: Zelis Auto |
$3,439.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,299.00
|
|
|
IMPLT SYSTEM HIP MODULAR 195X21MM
|
Facility
|
OP
|
$8,922.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,230.50 |
| Max. Negotiated Rate |
$8,475.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,353.20
|
| Rate for Payer: Cash Price |
$5,353.20
|
| Rate for Payer: Cash Price |
$5,353.20
|
| Rate for Payer: Cigna Commercial |
$7,583.70
|
| Rate for Payer: First Health Commercial |
$8,029.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,029.80
|
| Rate for Payer: GEHA Commercial |
$7,137.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,029.80
|
| Rate for Payer: Humana ChoiceCare |
$2,319.72
|
| Rate for Payer: Multiplan All |
$8,119.02
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,353.20
|
| Rate for Payer: OMNI Networks Commercial |
$6,245.40
|
| Rate for Payer: One Health Plan PPO/POS |
$8,029.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,475.90
|
| Rate for Payer: Three Rivers Provider Network All |
$6,691.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7,851.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,230.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,297.46
|
| Rate for Payer: Zelis Auto |
$3,568.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,461.00
|
|
|
IMPLT SYSTEM HIP MODULAR 195X21MM
|
Facility
|
IP
|
$8,922.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,568.80 |
| Max. Negotiated Rate |
$8,475.90 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,137.60
|
| Rate for Payer: Cash Price |
$5,353.20
|
| Rate for Payer: Cash Price |
$5,353.20
|
| Rate for Payer: Cigna Commercial |
$7,583.70
|
| Rate for Payer: First Health Commercial |
$8,029.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8,029.80
|
| Rate for Payer: GEHA Commercial |
$6,245.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8,029.80
|
| Rate for Payer: Multiplan All |
$8,119.02
|
| Rate for Payer: OMNI Networks Commercial |
$6,245.40
|
| Rate for Payer: One Health Plan PPO/POS |
$8,029.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8,475.90
|
| Rate for Payer: Three Rivers Provider Network All |
$6,691.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8,297.46
|
| Rate for Payer: Zelis Auto |
$3,568.80
|
|
|
IMPLT SYSTEM HIP MODULAR RESTORATION
|
Facility
|
IP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,607.20 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,214.40
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$8,062.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
|
|
IMPLT SYSTEM HIP MODULAR RESTORATION
|
Facility
|
OP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006379
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,879.50 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$9,214.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Humana ChoiceCare |
$2,994.68
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,910.80
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,135.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,879.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,759.00
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 21MM
|
Facility
|
OP
|
$11,675.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,918.75 |
| Max. Negotiated Rate |
$11,091.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,005.00
|
| Rate for Payer: Cash Price |
$7,005.00
|
| Rate for Payer: Cash Price |
$7,005.00
|
| Rate for Payer: Cigna Commercial |
$9,923.75
|
| Rate for Payer: First Health Commercial |
$10,507.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,507.50
|
| Rate for Payer: GEHA Commercial |
$9,340.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,507.50
|
| Rate for Payer: Humana ChoiceCare |
$3,035.50
|
| Rate for Payer: Multiplan All |
$10,624.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,005.00
|
| Rate for Payer: OMNI Networks Commercial |
$8,172.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,507.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,091.25
|
| Rate for Payer: Three Rivers Provider Network All |
$8,756.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,274.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,918.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,857.75
|
| Rate for Payer: Zelis Auto |
$4,670.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,837.50
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 21MM
|
Facility
|
IP
|
$11,675.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,670.00 |
| Max. Negotiated Rate |
$11,091.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,340.00
|
| Rate for Payer: Cash Price |
$7,005.00
|
| Rate for Payer: Cash Price |
$7,005.00
|
| Rate for Payer: Cigna Commercial |
$9,923.75
|
| Rate for Payer: First Health Commercial |
$10,507.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,507.50
|
| Rate for Payer: GEHA Commercial |
$8,172.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,507.50
|
| Rate for Payer: Multiplan All |
$10,624.25
|
| Rate for Payer: OMNI Networks Commercial |
$8,172.50
|
| Rate for Payer: One Health Plan PPO/POS |
$10,507.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,091.25
|
| Rate for Payer: Three Rivers Provider Network All |
$8,756.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,857.75
|
| Rate for Payer: Zelis Auto |
$4,670.00
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 25MM
|
Facility
|
OP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006182
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,879.50 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$9,214.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Humana ChoiceCare |
$2,994.68
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,910.80
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,135.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,879.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,759.00
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 25MM
|
Facility
|
IP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006182
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,607.20 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,214.40
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$8,062.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 27MM
|
Facility
|
OP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006178
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,879.50 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$9,214.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Humana ChoiceCare |
$2,994.68
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,910.80
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10,135.84
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,879.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,759.00
|
|
|
IMPLT SYSTEM HIP MODULAR SIZE 27MM
|
Facility
|
IP
|
$11,518.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7006178
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,607.20 |
| Max. Negotiated Rate |
$10,942.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$9,214.40
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cash Price |
$6,910.80
|
| Rate for Payer: Cigna Commercial |
$9,790.30
|
| Rate for Payer: First Health Commercial |
$10,366.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$10,366.20
|
| Rate for Payer: GEHA Commercial |
$8,062.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$10,366.20
|
| Rate for Payer: Multiplan All |
$10,481.38
|
| Rate for Payer: OMNI Networks Commercial |
$8,062.60
|
| Rate for Payer: One Health Plan PPO/POS |
$10,366.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$10,942.10
|
| Rate for Payer: Three Rivers Provider Network All |
$8,638.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$10,711.74
|
| Rate for Payer: Zelis Auto |
$4,607.20
|
|
|
IMPLT SYSTEM INTERNALBRACE LIG AUG REP
|
Facility
|
IP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,906.00 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,812.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,085.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
|
|
IMPLT SYSTEM INTERNALBRACE LIG AUG REP
|
Facility
|
OP
|
$7,265.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7003243
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,816.25 |
| Max. Negotiated Rate |
$6,901.75 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cash Price |
$4,359.00
|
| Rate for Payer: Cigna Commercial |
$6,175.25
|
| Rate for Payer: First Health Commercial |
$6,538.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,538.50
|
| Rate for Payer: GEHA Commercial |
$5,812.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,538.50
|
| Rate for Payer: Humana ChoiceCare |
$1,888.90
|
| Rate for Payer: Multiplan All |
$6,611.15
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,359.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,085.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,538.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$6,901.75
|
| Rate for Payer: Three Rivers Provider Network All |
$5,448.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,393.20
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,816.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,756.45
|
| Rate for Payer: Zelis Auto |
$2,906.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,632.50
|
|
|
IMPLT SYSTEM MINI STEM 8X83
|
Facility
|
OP
|
$6,151.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.75 |
| Max. Negotiated Rate |
$5,843.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,690.60
|
| Rate for Payer: Cash Price |
$3,690.60
|
| Rate for Payer: Cash Price |
$3,690.60
|
| Rate for Payer: Cigna Commercial |
$5,228.35
|
| Rate for Payer: First Health Commercial |
$5,535.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.90
|
| Rate for Payer: GEHA Commercial |
$4,920.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.90
|
| Rate for Payer: Humana ChoiceCare |
$1,599.26
|
| Rate for Payer: Multiplan All |
$5,597.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$3,690.60
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,843.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,613.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$5,412.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,537.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,720.43
|
| Rate for Payer: Zelis Auto |
$2,460.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,075.50
|
|
|
IMPLT SYSTEM MINI STEM 8X83
|
Facility
|
IP
|
$6,151.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.40 |
| Max. Negotiated Rate |
$5,843.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,920.80
|
| Rate for Payer: Cash Price |
$3,690.60
|
| Rate for Payer: Cash Price |
$3,690.60
|
| Rate for Payer: Cigna Commercial |
$5,228.35
|
| Rate for Payer: First Health Commercial |
$5,535.90
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$5,535.90
|
| Rate for Payer: GEHA Commercial |
$4,305.70
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$5,535.90
|
| Rate for Payer: Multiplan All |
$5,597.41
|
| Rate for Payer: OMNI Networks Commercial |
$4,305.70
|
| Rate for Payer: One Health Plan PPO/POS |
$5,535.90
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$5,843.45
|
| Rate for Payer: Three Rivers Provider Network All |
$4,613.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$5,720.43
|
| Rate for Payer: Zelis Auto |
$2,460.40
|
|
|
IMPLT SYSTEM MODULAR HIP 21MM
|
Facility
|
OP
|
$12,544.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,136.00 |
| Max. Negotiated Rate |
$11,916.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,526.40
|
| Rate for Payer: Cash Price |
$7,526.40
|
| Rate for Payer: Cash Price |
$7,526.40
|
| Rate for Payer: Cigna Commercial |
$10,662.40
|
| Rate for Payer: First Health Commercial |
$11,289.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,289.60
|
| Rate for Payer: GEHA Commercial |
$10,035.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,289.60
|
| Rate for Payer: Humana ChoiceCare |
$3,261.44
|
| Rate for Payer: Multiplan All |
$11,415.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,526.40
|
| Rate for Payer: OMNI Networks Commercial |
$8,780.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,289.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,916.80
|
| Rate for Payer: Three Rivers Provider Network All |
$9,408.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,038.72
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,136.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,665.92
|
| Rate for Payer: Zelis Auto |
$5,017.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,272.00
|
|
|
IMPLT SYSTEM MODULAR HIP 21MM
|
Facility
|
IP
|
$12,544.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,017.60 |
| Max. Negotiated Rate |
$11,916.80 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,035.20
|
| Rate for Payer: Cash Price |
$7,526.40
|
| Rate for Payer: Cash Price |
$7,526.40
|
| Rate for Payer: Cigna Commercial |
$10,662.40
|
| Rate for Payer: First Health Commercial |
$11,289.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,289.60
|
| Rate for Payer: GEHA Commercial |
$8,780.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,289.60
|
| Rate for Payer: Multiplan All |
$11,415.04
|
| Rate for Payer: OMNI Networks Commercial |
$8,780.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,289.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$11,916.80
|
| Rate for Payer: Three Rivers Provider Network All |
$9,408.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,665.92
|
| Rate for Payer: Zelis Auto |
$5,017.60
|
|
|
IMPLT SYSTEM MODULAR HIP 23MM
|
Facility
|
OP
|
$12,874.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,218.50 |
| Max. Negotiated Rate |
$12,230.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$7,724.40
|
| Rate for Payer: Cash Price |
$7,724.40
|
| Rate for Payer: Cash Price |
$7,724.40
|
| Rate for Payer: Cigna Commercial |
$10,942.90
|
| Rate for Payer: First Health Commercial |
$11,586.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,586.60
|
| Rate for Payer: GEHA Commercial |
$10,299.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,586.60
|
| Rate for Payer: Humana ChoiceCare |
$3,347.24
|
| Rate for Payer: Multiplan All |
$11,715.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$7,724.40
|
| Rate for Payer: OMNI Networks Commercial |
$9,011.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,586.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,230.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,655.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$11,329.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3,218.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,972.82
|
| Rate for Payer: Zelis Auto |
$5,149.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$6,437.00
|
|
|
IMPLT SYSTEM MODULAR HIP 23MM
|
Facility
|
IP
|
$12,874.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,149.60 |
| Max. Negotiated Rate |
$12,230.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$10,299.20
|
| Rate for Payer: Cash Price |
$7,724.40
|
| Rate for Payer: Cash Price |
$7,724.40
|
| Rate for Payer: Cigna Commercial |
$10,942.90
|
| Rate for Payer: First Health Commercial |
$11,586.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$11,586.60
|
| Rate for Payer: GEHA Commercial |
$9,011.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$11,586.60
|
| Rate for Payer: Multiplan All |
$11,715.34
|
| Rate for Payer: OMNI Networks Commercial |
$9,011.80
|
| Rate for Payer: One Health Plan PPO/POS |
$11,586.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$12,230.30
|
| Rate for Payer: Three Rivers Provider Network All |
$9,655.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$11,972.82
|
| Rate for Payer: Zelis Auto |
$5,149.60
|
|
