|
GRAFT AMNIOEXCEL 18 MM
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$315.00 |
| Max. Negotiated Rate |
$508.20 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$420.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$508.20
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$462.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$315.00
|
|
|
GRAFT AMNIOEXCEL 18 MM
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$50.61 |
| Max. Negotiated Rate |
$533.66 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$420.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$508.20
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$462.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$315.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$50.61
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$55.65
|
|
|
GRAFT AMNIO EXCEL 24 MM
|
Facility
|
OP
|
$2,450.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$592.90 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$490.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$592.90
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$539.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$367.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$59.05
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$64.92
|
|
|
GRAFT AMNIO EXCEL 24 MM
|
Facility
|
IP
|
$2,450.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$367.50 |
| Max. Negotiated Rate |
$592.90 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$592.90
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$539.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$367.50
|
|
|
GRAFT AMNIO EXCEL 2CM X3 CM
|
Facility
|
OP
|
$3,150.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684030
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$762.30 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$630.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$762.30
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$693.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$472.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$75.92
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$83.47
|
|
|
GRAFT AMNIO EXCEL 2CM X3 CM
|
Facility
|
IP
|
$3,150.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684030
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$472.50 |
| Max. Negotiated Rate |
$762.30 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$630.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$762.30
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$693.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$472.50
|
|
|
GRAFT AMNIO EXCEL 3.5 CM X 3.5
|
Facility
|
OP
|
$3,412.50
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$82.24 |
| Max. Negotiated Rate |
$825.83 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$682.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$825.83
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$750.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$511.88
|
| Rate for Payer: UnitedHealthcare Community & State |
$82.24
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$90.43
|
|
|
GRAFT AMNIO EXCEL 3.5 CM X 3.5
|
Facility
|
IP
|
$3,412.50
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684032
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$511.88 |
| Max. Negotiated Rate |
$825.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$682.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$825.83
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$750.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$511.88
|
|
|
GRAFT AMNIO EXCEL 4CMX 4 CM
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.04 |
| Max. Negotiated Rate |
$863.94 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$714.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$863.94
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$785.40
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$535.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$86.04
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$94.61
|
|
|
GRAFT AMNIO EXCEL 4CMX 4 CM
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684034
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$863.94 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$714.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$863.94
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$785.40
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$535.50
|
|
|
GRAFT AMNIO EXCEL 5CMX 5 CM
|
Facility
|
OP
|
$4,025.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$97.00 |
| Max. Negotiated Rate |
$974.05 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$805.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$974.05
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$885.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$603.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$97.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$106.66
|
|
|
GRAFT AMNIO EXCEL 5CMX 5 CM
|
Facility
|
IP
|
$4,025.00
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$603.75 |
| Max. Negotiated Rate |
$974.05 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$805.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$974.05
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$885.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$603.75
|
|
|
GRAFT AMNIO EXCEL PER SQ CM
|
Facility
|
OP
|
$278.57
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684032W
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$533.66 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$156.71
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$67.41
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$41.79
|
| Rate for Payer: UnitedHealthcare Community & State |
$6.71
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$7.38
|
|
|
GRAFT AMNIO EXCEL PER SQ CM
|
Facility
|
IP
|
$278.57
|
|
|
Service Code
|
HCPCS Q4137
|
| Hospital Charge Code |
270684032W
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$67.41 |
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$67.41
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$41.79
|
|
|
GRAFT AMNIO MATRIX .5 ML SSPNS
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
270684063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.04 |
| Max. Negotiated Rate |
$1,785.00 |
| Rate for Payer: Aetna Commercial |
$1,356.60
|
| Rate for Payer: Aetna Medicare Advantage |
$1,071.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$910.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$910.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$714.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$910.35
|
| Rate for Payer: Cigna Commercial |
$1,785.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$863.94
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$785.40
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$535.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$86.04
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$94.61
|
|
|
GRAFT AMNIO MATRIX .5 ML SSPNS
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
HCPCS Q4139
|
| Hospital Charge Code |
270684063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$863.94 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$714.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$863.94
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$785.40
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$535.50
|
|
|
GRAFT AMNION MATRIX 3CMX3CM
|
Facility
|
OP
|
$12,250.00
|
|
|
Service Code
|
HCPCS Q4148
|
| Hospital Charge Code |
270687488
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$140.45 |
| Max. Negotiated Rate |
$2,964.50 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,450.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,964.50
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$2,695.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,837.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$295.23
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$324.62
|
|
|
GRAFT AMNION MATRIX 3CMX3CM
|
Facility
|
IP
|
$12,250.00
|
|
|
Service Code
|
HCPCS Q4148
|
| Hospital Charge Code |
270687488
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,837.50 |
| Max. Negotiated Rate |
$2,964.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,450.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,964.50
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$2,695.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,837.50
|
|
|
GRAFT AMNIOTIC MEMBRANE 4X8CM
|
Facility
|
IP
|
$15,690.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
270694408
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,353.50 |
| Max. Negotiated Rate |
$3,796.98 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,138.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,796.98
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$3,451.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,353.50
|
|
|
GRAFT AMNIOTIC MEMBRANE 4X8CM
|
Facility
|
OP
|
$15,690.00
|
|
|
Service Code
|
HCPCS Q4205
|
| Hospital Charge Code |
270694408
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$140.45 |
| Max. Negotiated Rate |
$3,796.98 |
| Rate for Payer: Aetna Commercial |
$402.12
|
| Rate for Payer: Aetna Medicare Advantage |
$479.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$533.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,138.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$533.66
|
| Rate for Payer: Cigna Commercial |
$296.35
|
| Rate for Payer: Cigna Medicare Advantage |
$147.84
|
| Rate for Payer: Clover Medicare Advantage |
$140.45
|
| Rate for Payer: EmblemHealth Commercial |
$443.52
|
| Rate for Payer: Humana Medicare Advantage |
$152.28
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$147.84
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,796.98
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$3,451.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,353.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$378.13
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$415.79
|
|
|
GRAFT AMNITIC MEMBRANE 4X4CM
|
Facility
|
OP
|
$8,225.00
|
|
| Hospital Charge Code |
270701104
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.22 |
| Max. Negotiated Rate |
$4,112.50 |
| Rate for Payer: Aetna Commercial |
$3,125.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,467.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,097.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,097.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,645.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,097.38
|
| Rate for Payer: Cigna Commercial |
$4,112.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,990.45
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,809.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,233.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$198.22
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$217.96
|
|
|
GRAFT AMNITIC MEMBRANE 4X4CM
|
Facility
|
IP
|
$8,225.00
|
|
| Hospital Charge Code |
270701104
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.75 |
| Max. Negotiated Rate |
$1,990.45 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,645.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,990.45
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,809.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,233.75
|
|
|
GRAFT ANTERIOR TIBIALIS SHORT
|
Facility
|
OP
|
$9,725.00
|
|
| Hospital Charge Code |
270675480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$234.37 |
| Max. Negotiated Rate |
$4,862.50 |
| Rate for Payer: Aetna Commercial |
$3,695.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,917.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,479.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,479.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,945.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,479.88
|
| Rate for Payer: Cigna Commercial |
$4,862.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,353.45
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$2,139.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,458.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$234.37
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$257.71
|
|
|
GRAFT ANTERIOR TIBIALIS SHORT
|
Facility
|
IP
|
$9,725.00
|
|
| Hospital Charge Code |
270675480
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,458.75 |
| Max. Negotiated Rate |
$2,353.45 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,945.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,353.45
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$2,139.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,458.75
|
|
|
GRAFT ANTERIOR TIBIALIS TENDON
|
Facility
|
IP
|
$10,534.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
270675692
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,580.17 |
| Max. Negotiated Rate |
$2,549.35 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,106.90
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,549.35
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$2,317.59
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,580.17
|
|
