|
Complement C4, Serum
|
Facility
|
OP
|
$667.59
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39888019
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$333.80 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$333.80
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$200.28
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$100.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$17.69
|
|
|
Complement C4, Serum
|
Facility
|
IP
|
$667.59
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39888019
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$100.14 |
| Max. Negotiated Rate |
$100.14 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$100.14
|
|
|
COMPLEMENT C5
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
38476297
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$15.60
|
|
|
COMPLEMENT C5
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
38476297
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$52.00
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$31.20
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$15.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$2.76
|
|
|
COMPLEMENT C5
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900463
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
COMPLEMENT C5
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900463
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$117.00
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$10.34
|
|
|
COMPLEMENT C6
|
Facility
|
OP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900464
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$41.25
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$24.75
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$2.19
|
|
|
COMPLEMENT C6
|
Facility
|
IP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900464
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
|
|
COMPLEMENT C7
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900465
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$117.00
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$10.34
|
|
|
COMPLEMENT C7
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900465
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
COMPLEMENT C8
|
Facility
|
OP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900466
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$41.25
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$24.75
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$2.19
|
|
|
COMPLEMENT C8
|
Facility
|
IP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900466
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
|
|
COMPLEMENT C9
|
Facility
|
OP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900467
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: Aetna Medicare Advantage |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$17.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.32
|
| Rate for Payer: Cigna Commercial |
$41.25
|
| Rate for Payer: Cigna Medicare Advantage |
$12.00
|
| Rate for Payer: Clover Medicare Advantage |
$11.40
|
| Rate for Payer: EmblemHealth Commercial |
$36.00
|
| Rate for Payer: Humana Medicare Advantage |
$12.36
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$24.75
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.00
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$2.19
|
|
|
COMPLEMENT C9
|
Facility
|
IP
|
$82.50
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
39900467
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$12.38
|
|
|
COMPLEMENT TOTAL***
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
3010857
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$26.22
|
| Rate for Payer: Aetna Medicare Advantage |
$20.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.59
|
| Rate for Payer: Cigna Commercial |
$34.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$20.70
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$1.66
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.83
|
|
|
COMPLEMENT TOTAL***
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
3010857
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.35
|
|
|
COMPLEMENT TOTAL CH100, SERUM
|
Facility
|
IP
|
$220.15
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3007333
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$33.02 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.02
|
|
|
COMPLEMENT TOTAL CH100, SERUM
|
Facility
|
OP
|
$220.15
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3007333
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$55.27
|
| Rate for Payer: Aetna Medicare Advantage |
$65.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$30.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$73.35
|
| Rate for Payer: Cigna Commercial |
$110.08
|
| Rate for Payer: Cigna Medicare Advantage |
$20.32
|
| Rate for Payer: Clover Medicare Advantage |
$19.30
|
| Rate for Payer: EmblemHealth Commercial |
$60.96
|
| Rate for Payer: Humana Medicare Advantage |
$20.93
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$20.32
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$66.05
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$16.26
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$5.83
|
|
|
COMPLEMENT TOTAL(CH50)
|
Facility
|
OP
|
$220.15
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3007325
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$55.27
|
| Rate for Payer: Aetna Medicare Advantage |
$65.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$30.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$73.35
|
| Rate for Payer: Cigna Commercial |
$110.08
|
| Rate for Payer: Cigna Medicare Advantage |
$20.32
|
| Rate for Payer: Clover Medicare Advantage |
$19.30
|
| Rate for Payer: EmblemHealth Commercial |
$60.96
|
| Rate for Payer: Humana Medicare Advantage |
$20.93
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$20.32
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$66.05
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$16.26
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$5.83
|
|
|
COMPLEMENT TOTAL(CH50)
|
Facility
|
IP
|
$220.15
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3007325
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$33.02 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.02
|
|
|
COMPLEMENT, TOTAL (CH50)
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
38476090
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$34.05 |
| Max. Negotiated Rate |
$34.05 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$34.05
|
|
|
COMPLEMENT, TOTAL (CH50)
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
38476090
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$55.27
|
| Rate for Payer: Aetna Medicare Advantage |
$65.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$30.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$73.35
|
| Rate for Payer: Cigna Commercial |
$113.50
|
| Rate for Payer: Cigna Medicare Advantage |
$20.32
|
| Rate for Payer: Clover Medicare Advantage |
$19.30
|
| Rate for Payer: EmblemHealth Commercial |
$60.96
|
| Rate for Payer: Humana Medicare Advantage |
$20.93
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$20.32
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$68.10
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$34.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$16.26
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$6.02
|
|
|
COMPLEMENT,TOTAL (CH50)
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
39900197
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
COMPLEMENT,TOTAL (CH50)
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
39900197
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$55.27
|
| Rate for Payer: Aetna Medicare Advantage |
$65.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$73.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$30.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$73.35
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$20.32
|
| Rate for Payer: Clover Medicare Advantage |
$19.30
|
| Rate for Payer: EmblemHealth Commercial |
$60.96
|
| Rate for Payer: Humana Medicare Advantage |
$20.93
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$20.32
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$117.00
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$16.26
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.32
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$10.34
|
|
|
COMPLERA 200MG-25MG-300MG
|
Facility
|
OP
|
$470.34
|
|
|
Service Code
|
NDC 61958110101
|
| Hospital Charge Code |
6063943371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$235.17 |
| Rate for Payer: Aetna Commercial |
$178.73
|
| Rate for Payer: Aetna Medicare Advantage |
$141.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$119.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$119.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$119.94
|
| Rate for Payer: Cigna Commercial |
$235.17
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$141.10
|
| Rate for Payer: Oxford Commercial |
$94.07
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$70.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$94.07
|
| Rate for Payer: UnitedHealthcare Community & State |
$11.34
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$12.46
|
|
