|
INSERT TIBIAL PLATFORM 12.5MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.00 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,980.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,232.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
|
|
INSERT TIBIAL PLATFORM 12.5MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002227
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,868.75 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,980.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Humana ChoiceCare |
$1,943.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,485.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,578.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,868.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,737.50
|
|
|
INSERT TIBIAL RM/LL SZ5 8MM
|
Facility
|
IP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,938.80 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,877.60
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,392.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
|
|
INSERT TIBIAL RM/LL SZ5 8MM
|
Facility
|
OP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,211.75 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Humana ChoiceCare |
$1,260.22
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,908.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,211.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,423.50
|
|
|
INSERT TIBIAL ROTATING 12.5MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002229
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.00 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,980.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,232.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
|
|
INSERT TIBIAL ROTATING 12.5MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002229
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,868.75 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,980.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Humana ChoiceCare |
$1,943.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,485.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,578.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,868.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,737.50
|
|
|
INSERT TIBIAL ROTATING 15MM
|
Facility
|
OP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,868.75 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,980.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Humana ChoiceCare |
$1,943.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4,485.00
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$6,578.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,868.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$3,737.50
|
|
|
INSERT TIBIAL ROTATING 15MM
|
Facility
|
IP
|
$7,475.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.00 |
| Max. Negotiated Rate |
$7,101.25 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5,980.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cash Price |
$4,485.00
|
| Rate for Payer: Cigna Commercial |
$6,353.75
|
| Rate for Payer: First Health Commercial |
$6,727.50
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$6,727.50
|
| Rate for Payer: GEHA Commercial |
$5,232.50
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$6,727.50
|
| Rate for Payer: Multiplan All |
$6,802.25
|
| Rate for Payer: OMNI Networks Commercial |
$5,232.50
|
| Rate for Payer: One Health Plan PPO/POS |
$6,727.50
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7,101.25
|
| Rate for Payer: Three Rivers Provider Network All |
$5,606.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$6,951.75
|
| Rate for Payer: Zelis Auto |
$2,990.00
|
|
|
INSERT TIBIAL SIZE 3X9MM
|
Facility
|
IP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,938.80 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,877.60
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,392.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
|
|
INSERT TIBIAL SIZE 3X9MM
|
Facility
|
OP
|
$4,847.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,211.75 |
| Max. Negotiated Rate |
$4,604.65 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cash Price |
$2,908.20
|
| Rate for Payer: Cigna Commercial |
$4,119.95
|
| Rate for Payer: First Health Commercial |
$4,362.30
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$4,362.30
|
| Rate for Payer: GEHA Commercial |
$3,877.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$4,362.30
|
| Rate for Payer: Humana ChoiceCare |
$1,260.22
|
| Rate for Payer: Multiplan All |
$4,410.77
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,908.20
|
| Rate for Payer: OMNI Networks Commercial |
$3,392.90
|
| Rate for Payer: One Health Plan PPO/POS |
$4,362.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$4,604.65
|
| Rate for Payer: Three Rivers Provider Network All |
$3,635.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$4,265.36
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,211.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$4,507.71
|
| Rate for Payer: Zelis Auto |
$1,938.80
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,423.50
|
|
|
INSERT TIBIAL SIZE 4X8MM
|
Facility
|
OP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002232
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,012.50 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$3,240.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Humana ChoiceCare |
$1,053.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: New Mexico Health Connections Medicare |
$2,430.00
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,564.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$1,012.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$2,025.00
|
|
|
INSERT TIBIAL SIZE 4X8MM
|
Facility
|
IP
|
$4,050.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002232
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.00 |
| Max. Negotiated Rate |
$3,847.50 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$3,240.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cash Price |
$2,430.00
|
| Rate for Payer: Cigna Commercial |
$3,442.50
|
| Rate for Payer: First Health Commercial |
$3,645.00
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$3,645.00
|
| Rate for Payer: GEHA Commercial |
$2,835.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$3,645.00
|
| Rate for Payer: Multiplan All |
$3,685.50
|
| Rate for Payer: OMNI Networks Commercial |
$2,835.00
|
| Rate for Payer: One Health Plan PPO/POS |
$3,645.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$3,847.50
|
| Rate for Payer: Three Rivers Provider Network All |
$3,037.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$3,766.50
|
| Rate for Payer: Zelis Auto |
$1,620.00
|
|
|
INSERT TIBIAL SIZE 7X11MM
|
Facility
|
OP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002233
|
|
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
|
|
|
INSERT TIBIAL SIZE 7X11MM
|
Facility
|
IP
|
$3,654.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002233
|
|
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
|
|
|
INSERT TIBIAL STANDARD 17.5
|
Facility
|
OP
|
$10,009.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,502.25 |
| Max. Negotiated Rate |
$9,508.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cigna Commercial |
$8,507.65
|
| Rate for Payer: First Health Commercial |
$9,008.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,008.10
|
| Rate for Payer: GEHA Commercial |
$8,007.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,008.10
|
| Rate for Payer: Humana ChoiceCare |
$2,602.34
|
| Rate for Payer: Multiplan All |
$9,108.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,005.40
|
| Rate for Payer: OMNI Networks Commercial |
$7,006.30
|
| Rate for Payer: One Health Plan PPO/POS |
$9,008.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,508.55
|
| Rate for Payer: Three Rivers Provider Network All |
$7,506.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,807.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,502.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,308.37
|
| Rate for Payer: Zelis Auto |
$4,003.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,004.50
|
|
|
INSERT TIBIAL STANDARD 17.5
|
Facility
|
OP
|
$10,009.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,502.25 |
| Max. Negotiated Rate |
$9,508.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cigna Commercial |
$8,507.65
|
| Rate for Payer: First Health Commercial |
$9,008.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,008.10
|
| Rate for Payer: GEHA Commercial |
$8,007.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,008.10
|
| Rate for Payer: Humana ChoiceCare |
$2,602.34
|
| Rate for Payer: Multiplan All |
$9,108.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$6,005.40
|
| Rate for Payer: OMNI Networks Commercial |
$7,006.30
|
| Rate for Payer: One Health Plan PPO/POS |
$9,008.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,508.55
|
| Rate for Payer: Three Rivers Provider Network All |
$7,506.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$8,807.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,502.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,308.37
|
| Rate for Payer: Zelis Auto |
$4,003.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$5,004.50
|
|
|
INSERT TIBIAL STANDARD 17.5
|
Facility
|
IP
|
$10,009.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002217
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,003.60 |
| Max. Negotiated Rate |
$9,508.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,007.20
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cigna Commercial |
$8,507.65
|
| Rate for Payer: First Health Commercial |
$9,008.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,008.10
|
| Rate for Payer: GEHA Commercial |
$7,006.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,008.10
|
| Rate for Payer: Multiplan All |
$9,108.19
|
| Rate for Payer: OMNI Networks Commercial |
$7,006.30
|
| Rate for Payer: One Health Plan PPO/POS |
$9,008.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,508.55
|
| Rate for Payer: Three Rivers Provider Network All |
$7,506.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,308.37
|
| Rate for Payer: Zelis Auto |
$4,003.60
|
|
|
INSERT TIBIAL STANDARD 17.5
|
Facility
|
IP
|
$10,009.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,003.60 |
| Max. Negotiated Rate |
$9,508.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8,007.20
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cash Price |
$6,005.40
|
| Rate for Payer: Cigna Commercial |
$8,507.65
|
| Rate for Payer: First Health Commercial |
$9,008.10
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$9,008.10
|
| Rate for Payer: GEHA Commercial |
$7,006.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$9,008.10
|
| Rate for Payer: Multiplan All |
$9,108.19
|
| Rate for Payer: OMNI Networks Commercial |
$7,006.30
|
| Rate for Payer: One Health Plan PPO/POS |
$9,008.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$9,508.55
|
| Rate for Payer: Three Rivers Provider Network All |
$7,506.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$9,308.37
|
| Rate for Payer: Zelis Auto |
$4,003.60
|
|
|
INSERT TIBIAL UNI JOURNEY 9MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002234
|
|
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
|
|
|
INSERT TIBIAL UNI JOURNEY 9MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002234
|
|
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
|
|
|
INSERT TIBIAL UNI S3-4RM/LL8MM
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002235
|
|
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
|
|
|
INSERT TIBIAL UNI S3-4RM/LL8MM
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
7002235
|
|
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
|
|
|
INSERT TUN IP CATH PERC
|
Facility
|
IP
|
$644.00
|
|
|
Service Code
|
CPT 49418
|
| Hospital Charge Code |
6149418
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$175.81 |
| Max. Negotiated Rate |
$611.80 |
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cigna Commercial |
$547.40
|
| Rate for Payer: First Health Commercial |
$579.60
|
| Rate for Payer: First Health Workers Compensation |
$248.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$579.60
|
| Rate for Payer: GEHA Commercial |
$450.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$579.60
|
| Rate for Payer: Multiplan All |
$586.04
|
| Rate for Payer: OMNI Networks Commercial |
$450.80
|
| Rate for Payer: One Health Plan PPO/POS |
$579.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$611.80
|
| Rate for Payer: Three Rivers Provider Network All |
$483.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$598.92
|
| Rate for Payer: Zelis Auto |
$257.60
|
| Rate for Payer: Zelis Worker's Compensation |
$175.81
|
|
|
INSERT TUN IP CATH PERC
|
Facility
|
OP
|
$644.00
|
|
|
Service Code
|
CPT 49418
|
| Hospital Charge Code |
6149418
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$175.81 |
| Max. Negotiated Rate |
$6,701.96 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$3,134.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$386.40
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$3,134.47
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$2,483.13
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$3,350.98
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cigna Commercial |
$547.40
|
| Rate for Payer: First Health Commercial |
$579.60
|
| Rate for Payer: First Health Workers Compensation |
$248.65
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$579.60
|
| Rate for Payer: GEHA Commercial |
$515.20
|
| Rate for Payer: GEHA Medicare |
$3,350.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$579.60
|
| Rate for Payer: Humana ChoiceCare |
$3,686.08
|
| Rate for Payer: Humana Medicare Advantage |
$3,350.98
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$5,629.65
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$2,533.70
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$3,350.98
|
| Rate for Payer: Multiplan All |
$586.04
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5,696.67
|
| Rate for Payer: OMNI Networks Commercial |
$450.80
|
| Rate for Payer: One Health Plan PPO/POS |
$579.60
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$2,925.51
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$2,533.70
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$3,350.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$611.80
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$6,701.96
|
| Rate for Payer: Three Rivers Provider Network All |
$483.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$3,283.96
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2,533.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,350.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$598.92
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$3,350.98
|
| Rate for Payer: Zelis Auto |
$257.60
|
| Rate for Payer: Zelis Medicare |
$2,848.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4,021.18
|
| Rate for Payer: Zelis Worker's Compensation |
$175.81
|
|
|
INSERT TUN IP CATH W/PORT
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
CPT 49419
|
| Hospital Charge Code |
6149419
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$253.07 |
| Max. Negotiated Rate |
$880.65 |
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cigna Commercial |
$787.95
|
| Rate for Payer: First Health Commercial |
$834.30
|
| Rate for Payer: First Health Workers Compensation |
$357.91
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$834.30
|
| Rate for Payer: GEHA Commercial |
$648.90
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$834.30
|
| Rate for Payer: Multiplan All |
$843.57
|
| Rate for Payer: OMNI Networks Commercial |
$648.90
|
| Rate for Payer: One Health Plan PPO/POS |
$834.30
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$880.65
|
| Rate for Payer: Three Rivers Provider Network All |
$695.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$862.11
|
| Rate for Payer: Zelis Auto |
$370.80
|
| Rate for Payer: Zelis Worker's Compensation |
$253.07
|
|
