|
IMPLT SYSTEM RETRACTION SCROTAL DEEP
|
Facility
|
IP
|
$1,670.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002489
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$668.00 |
| Max. Negotiated Rate |
$1,586.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,336.00
|
| Rate for Payer: Cash Price |
$1,002.00
|
| Rate for Payer: Cash Price |
$1,002.00
|
| Rate for Payer: Cigna Commercial |
$1,419.50
|
| Rate for Payer: First Health Commercial |
$1,503.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,503.00
|
| Rate for Payer: GEHA Commercial |
$1,169.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,503.00
|
| Rate for Payer: Multiplan All |
$1,519.70
|
| Rate for Payer: OMNI Networks Commercial |
$1,169.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,503.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,586.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,252.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,553.10
|
| Rate for Payer: Zelis Auto |
$668.00
|
|
|
IMPLT SYSTEM RETRACTION SCROTAL DEEP
|
Facility
|
OP
|
$1,670.00
|
|
|
Service Code
|
CPT C1813
|
| Hospital Charge Code |
7002489
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$417.50 |
| Max. Negotiated Rate |
$1,586.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,002.00
|
| Rate for Payer: Cash Price |
$1,002.00
|
| Rate for Payer: Cash Price |
$1,002.00
|
| Rate for Payer: Cigna Commercial |
$1,419.50
|
| Rate for Payer: First Health Commercial |
$1,503.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$1,503.00
|
| Rate for Payer: GEHA Commercial |
$1,336.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$1,503.00
|
| Rate for Payer: Humana ChoiceCare |
$434.20
|
| Rate for Payer: Multiplan All |
$1,519.70
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,002.00
|
| Rate for Payer: OMNI Networks Commercial |
$1,169.00
|
| Rate for Payer: One Health Plan PPO/POS |
$1,503.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,586.50
|
| Rate for Payer: Three Rivers Provider Network All |
$1,252.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$1,469.60
|
| Rate for Payer: United Healthcare Managed Medicaid |
$417.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$1,553.10
|
| Rate for Payer: Zelis Auto |
$668.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$835.00
|
|
|
IMPLT SYSTEM SHOULDER REVERSE 36MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002315
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,522.40 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,044.80
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$2,664.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
|
|
IMPLT SYSTEM SHOULDER REVERSE 36MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002315
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$951.50 |
| Max. Negotiated Rate |
$3,615.70 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cash Price |
$2,283.60
|
| Rate for Payer: Cigna Commercial |
$3,235.10
|
| Rate for Payer: First Health Commercial |
$3,425.40
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,425.40
|
| Rate for Payer: GEHA Commercial |
$3,044.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,425.40
|
| Rate for Payer: Humana ChoiceCare |
$989.56
|
| Rate for Payer: Multiplan All |
$3,463.46
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,283.60
|
| Rate for Payer: OMNI Networks Commercial |
$2,664.20
|
| Rate for Payer: One Health Plan PPO/POS |
$3,425.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,615.70
|
| Rate for Payer: Three Rivers Provider Network All |
$2,854.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,349.28
|
| Rate for Payer: United Healthcare Managed Medicaid |
$951.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,539.58
|
| Rate for Payer: Zelis Auto |
$1,522.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,903.00
|
|
|
IMPLT THERASKIN 1.75 X 1.75
|
Facility
|
IP
|
$3,135.00
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
7007054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,254.00 |
| Max. Negotiated Rate |
$2,978.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,508.00
|
| Rate for Payer: Cash Price |
$1,881.00
|
| Rate for Payer: Cash Price |
$1,881.00
|
| Rate for Payer: Cigna Commercial |
$2,664.75
|
| Rate for Payer: First Health Commercial |
$2,821.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,821.50
|
| Rate for Payer: GEHA Commercial |
$2,194.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,821.50
|
| Rate for Payer: Multiplan All |
$2,852.85
|
| Rate for Payer: OMNI Networks Commercial |
$2,194.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,821.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,978.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,351.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,915.55
|
| Rate for Payer: Zelis Auto |
$1,254.00
|
|
|
IMPLT THERASKIN 1.75 X 1.75
|
Facility
|
OP
|
$3,135.00
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
7007054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.23 |
| Max. Negotiated Rate |
$2,978.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,881.00
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.23
|
| Rate for Payer: Cash Price |
$1,881.00
|
| Rate for Payer: Cash Price |
$1,881.00
|
| Rate for Payer: Cash Price |
$1,881.00
|
| Rate for Payer: Cigna Commercial |
$2,664.75
|
| Rate for Payer: First Health Commercial |
$2,821.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,821.50
|
| Rate for Payer: GEHA Commercial |
$58.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,821.50
|
| Rate for Payer: Humana ChoiceCare |
$815.10
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.29
|
| Rate for Payer: Multiplan All |
$2,852.85
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,881.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,194.50
|
| Rate for Payer: One Health Plan PPO/POS |
$2,821.50
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,978.25
|
| Rate for Payer: Three Rivers Provider Network All |
$2,351.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,758.80
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,915.55
|
| Rate for Payer: Zelis Auto |
$1,254.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,567.50
|
|
|
IMPLT THERASKIN 6CM X 6CM
|
Facility
|
IP
|
$3,205.80
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
7009250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,282.32 |
| Max. Negotiated Rate |
$3,045.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,564.64
|
| Rate for Payer: Cash Price |
$1,923.48
|
| Rate for Payer: Cash Price |
$1,923.48
|
| Rate for Payer: Cigna Commercial |
$2,724.93
|
| Rate for Payer: First Health Commercial |
$2,885.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,885.22
|
| Rate for Payer: GEHA Commercial |
$2,244.06
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,885.22
|
| Rate for Payer: Multiplan All |
$2,917.28
|
| Rate for Payer: OMNI Networks Commercial |
$2,244.06
|
| Rate for Payer: One Health Plan PPO/POS |
$2,885.22
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,045.51
|
| Rate for Payer: Three Rivers Provider Network All |
$2,404.35
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,981.39
|
| Rate for Payer: Zelis Auto |
$1,282.32
|
|
|
IMPLT THERASKIN 6CM X 6CM
|
Facility
|
OP
|
$3,205.80
|
|
|
Service Code
|
CPT Q4121
|
| Hospital Charge Code |
7009250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.23 |
| Max. Negotiated Rate |
$3,045.51 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,923.48
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$65.92
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$52.23
|
| Rate for Payer: Cash Price |
$1,923.48
|
| Rate for Payer: Cash Price |
$1,923.48
|
| Rate for Payer: Cash Price |
$1,923.48
|
| Rate for Payer: Cigna Commercial |
$2,724.93
|
| Rate for Payer: First Health Commercial |
$2,885.22
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,885.22
|
| Rate for Payer: GEHA Commercial |
$58.02
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,885.22
|
| Rate for Payer: Humana ChoiceCare |
$833.51
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$53.29
|
| Rate for Payer: Multiplan All |
$2,917.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1,923.48
|
| Rate for Payer: OMNI Networks Commercial |
$2,244.06
|
| Rate for Payer: One Health Plan PPO/POS |
$2,885.22
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$61.53
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$53.29
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,045.51
|
| Rate for Payer: Three Rivers Provider Network All |
$2,404.35
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2,821.10
|
| Rate for Payer: United Healthcare Managed Medicaid |
$53.29
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,981.39
|
| Rate for Payer: Zelis Auto |
$1,282.32
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,602.90
|
|
|
IMPLT THREADED PARTIALLY SCREW 4.0X10MM
|
Facility
|
IP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.00 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$844.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$738.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
|
|
IMPLT THREADED PARTIALLY SCREW 4.0X10MM
|
Facility
|
OP
|
$1,055.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
7001089
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.75 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$896.75
|
| Rate for Payer: First Health Commercial |
$949.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$949.50
|
| Rate for Payer: GEHA Commercial |
$844.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$949.50
|
| Rate for Payer: Humana ChoiceCare |
$274.30
|
| Rate for Payer: Multiplan All |
$960.05
|
| Rate for Payer: New Mexico Health Connections Medicare |
$633.00
|
| Rate for Payer: OMNI Networks Commercial |
$738.50
|
| Rate for Payer: One Health Plan PPO/POS |
$949.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$1,002.25
|
| Rate for Payer: Three Rivers Provider Network All |
$791.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$928.40
|
| Rate for Payer: United Healthcare Managed Medicaid |
$263.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$981.15
|
| Rate for Payer: Zelis Auto |
$422.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$527.50
|
|
|
IMPLT TIBIAL AUGMENT HALF BLOCK
|
Facility
|
OP
|
$3,648.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$912.00 |
| Max. Negotiated Rate |
$3,465.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cigna Commercial |
$3,100.80
|
| Rate for Payer: First Health Commercial |
$3,283.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,283.20
|
| Rate for Payer: GEHA Commercial |
$2,918.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,283.20
|
| Rate for Payer: Humana ChoiceCare |
$948.48
|
| Rate for Payer: Multiplan All |
$3,319.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,188.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,553.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,283.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,465.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,736.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,210.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$912.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,392.64
|
| Rate for Payer: Zelis Auto |
$1,459.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,824.00
|
|
|
IMPLT TIBIAL AUGMENT HALF BLOCK
|
Facility
|
IP
|
$3,648.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007027
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.20 |
| Max. Negotiated Rate |
$3,465.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,918.40
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cigna Commercial |
$3,100.80
|
| Rate for Payer: First Health Commercial |
$3,283.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,283.20
|
| Rate for Payer: GEHA Commercial |
$2,553.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,283.20
|
| Rate for Payer: Multiplan All |
$3,319.68
|
| Rate for Payer: OMNI Networks Commercial |
$2,553.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,283.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,465.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,736.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,392.64
|
| Rate for Payer: Zelis Auto |
$1,459.20
|
|
|
IMPLT TIBIAL AUGMENT HALF BLOCK
|
Facility
|
OP
|
$3,648.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$912.00 |
| Max. Negotiated Rate |
$3,465.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cigna Commercial |
$3,100.80
|
| Rate for Payer: First Health Commercial |
$3,283.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,283.20
|
| Rate for Payer: GEHA Commercial |
$2,918.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,283.20
|
| Rate for Payer: Humana ChoiceCare |
$948.48
|
| Rate for Payer: Multiplan All |
$3,319.68
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,188.80
|
| Rate for Payer: OMNI Networks Commercial |
$2,553.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,283.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,465.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,736.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,210.24
|
| Rate for Payer: United Healthcare Managed Medicaid |
$912.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,392.64
|
| Rate for Payer: Zelis Auto |
$1,459.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,824.00
|
|
|
IMPLT TIBIAL AUGMENT HALF BLOCK
|
Facility
|
IP
|
$3,648.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007028
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.20 |
| Max. Negotiated Rate |
$3,465.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,918.40
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cash Price |
$2,188.80
|
| Rate for Payer: Cigna Commercial |
$3,100.80
|
| Rate for Payer: First Health Commercial |
$3,283.20
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,283.20
|
| Rate for Payer: GEHA Commercial |
$2,553.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,283.20
|
| Rate for Payer: Multiplan All |
$3,319.68
|
| Rate for Payer: OMNI Networks Commercial |
$2,553.60
|
| Rate for Payer: One Health Plan PPO/POS |
$3,283.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,465.60
|
| Rate for Payer: Three Rivers Provider Network All |
$2,736.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,392.64
|
| Rate for Payer: Zelis Auto |
$1,459.20
|
|
|
IMPLT TIBIAL BASEPLATE #1
|
Facility
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.60 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,879.20
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,519.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
|
|
IMPLT TIBIAL BASEPLATE #1
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$899.75 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,879.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Humana ChoiceCare |
$935.74
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,159.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,167.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$899.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,799.50
|
|
|
IMPLT TIBIAL BASEPLATE #2
|
Facility
|
OP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$899.75 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,879.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Humana ChoiceCare |
$935.74
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,159.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,167.12
|
| Rate for Payer: United Healthcare Managed Medicaid |
$899.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,799.50
|
|
|
IMPLT TIBIAL BASEPLATE #2
|
Facility
|
IP
|
$3,599.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.60 |
| Max. Negotiated Rate |
$3,419.05 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,879.20
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cash Price |
$2,159.40
|
| Rate for Payer: Cigna Commercial |
$3,059.15
|
| Rate for Payer: First Health Commercial |
$3,239.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,239.10
|
| Rate for Payer: GEHA Commercial |
$2,519.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,239.10
|
| Rate for Payer: Multiplan All |
$3,275.09
|
| Rate for Payer: OMNI Networks Commercial |
$2,519.30
|
| Rate for Payer: One Health Plan PPO/POS |
$3,239.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,419.05
|
| Rate for Payer: Three Rivers Provider Network All |
$2,699.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,347.07
|
| Rate for Payer: Zelis Auto |
$1,439.60
|
|
|
IMPLT TIBIAL BEARING
|
Facility
|
IP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,948.80 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,897.60
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,410.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
|
|
IMPLT TIBIAL BEARING
|
Facility
|
OP
|
$4,872.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7007042
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.00 |
| Max. Negotiated Rate |
$4,628.40 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,923.20
|
| Rate for Payer: Cigna Commercial |
$4,141.20
|
| Rate for Payer: First Health Commercial |
$4,384.80
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,384.80
|
| Rate for Payer: GEHA Commercial |
$3,897.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,384.80
|
| Rate for Payer: Humana ChoiceCare |
$1,266.72
|
| Rate for Payer: Multiplan All |
$4,433.52
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,923.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,410.40
|
| Rate for Payer: One Health Plan PPO/POS |
$4,384.80
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,628.40
|
| Rate for Payer: Three Rivers Provider Network All |
$3,654.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,287.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,218.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,530.96
|
| Rate for Payer: Zelis Auto |
$1,948.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,436.00
|
|
|
IMPLT TIBIAL BEARING INSERT
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT TIBIAL BEARING INSERT
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT TIBIAL BEARING INSERT 11MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
|
IMPLT TIBIAL BEARING INSERT 11MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7008064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,923.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Humana ChoiceCare |
$950.04
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,192.40
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,215.52
|
| Rate for Payer: United Healthcare Managed Medicaid |
$913.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1,827.00
|
|
|
IMPLT TIBIAL BEARING INSERT CR
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7003291
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.60 |
| Max. Negotiated Rate |
$3,471.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,923.20
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$3,105.90
|
| Rate for Payer: First Health Commercial |
$3,288.60
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,288.60
|
| Rate for Payer: GEHA Commercial |
$2,557.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,288.60
|
| Rate for Payer: Multiplan All |
$3,325.14
|
| Rate for Payer: OMNI Networks Commercial |
$2,557.80
|
| Rate for Payer: One Health Plan PPO/POS |
$3,288.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,471.30
|
| Rate for Payer: Three Rivers Provider Network All |
$2,740.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,398.22
|
| Rate for Payer: Zelis Auto |
$1,461.60
|
|
