|
BAL QUAN OTW 4.5x8m 380810845
|
Facility
|
IP
|
$1,295.00
|
|
| Hospital Charge Code |
270639418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
|
|
BAL QUAN OTW 4.5x8m 380810845
|
Facility
|
OP
|
$1,295.00
|
|
| Hospital Charge Code |
270639418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$647.50 |
| Rate for Payer: Aetna Commercial |
$492.10
|
| Rate for Payer: Aetna Medicare Advantage |
$388.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$330.23
|
| Rate for Payer: Cigna Commercial |
$647.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$388.50
|
| Rate for Payer: Oxford Commercial |
$259.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$259.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$31.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$34.32
|
|
|
BAL QUAN OTW 5.0x12m 380811250
|
Facility
|
OP
|
$1,295.00
|
|
| Hospital Charge Code |
270639421
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$647.50 |
| Rate for Payer: Aetna Commercial |
$492.10
|
| Rate for Payer: Aetna Medicare Advantage |
$388.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$259.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$330.23
|
| Rate for Payer: Cigna Commercial |
$647.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$313.39
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$284.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$31.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$34.32
|
|
|
BAL QUAN OTW 5.0x12m 380811250
|
Facility
|
IP
|
$1,295.00
|
|
| Hospital Charge Code |
270639421
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$313.39 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$259.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$313.39
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$284.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
|
|
BAL QUAN OTW 5.0x8m 380810850
|
Facility
|
OP
|
$1,295.00
|
|
| Hospital Charge Code |
270639420
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$647.50 |
| Rate for Payer: Aetna Commercial |
$492.10
|
| Rate for Payer: Aetna Medicare Advantage |
$388.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$330.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$330.23
|
| Rate for Payer: Cigna Commercial |
$647.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$388.50
|
| Rate for Payer: Oxford Commercial |
$259.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$259.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$31.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$34.32
|
|
|
BAL QUAN OTW 5.0x8m 380810850
|
Facility
|
IP
|
$1,295.00
|
|
| Hospital Charge Code |
270639420
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$194.25
|
|
|
BALSAM PERU/TRYPSIN SPRAY
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
6000541
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$24.32
|
| Rate for Payer: Aetna Medicare Advantage |
$19.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$16.32
|
| Rate for Payer: Cigna Commercial |
$32.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$19.20
|
| Rate for Payer: Oxford Commercial |
$12.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$9.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.80
|
| Rate for Payer: UnitedHealthcare Community & State |
$1.54
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.70
|
|
|
BALSAM PERU/TRYPSIN SPRAY
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
6000541
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$9.60
|
|
|
BAL STE 5x20x135cm 39031-50201
|
Facility
|
IP
|
$2,400.00
|
|
| Hospital Charge Code |
270637714V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$580.80 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$480.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$580.80
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$528.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$360.00
|
|
|
BAL STE 5x20x135cm 39031-50201
|
Facility
|
OP
|
$2,400.00
|
|
| Hospital Charge Code |
270637714V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.84 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$912.00
|
| Rate for Payer: Aetna Medicare Advantage |
$720.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$480.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$612.00
|
| Rate for Payer: Cigna Commercial |
$1,200.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$580.80
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$528.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$360.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$57.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$63.60
|
|
|
BAL STER 6x20x135cm39031-60201
|
Facility
|
IP
|
$2,325.00
|
|
| Hospital Charge Code |
270637715V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.75 |
| Max. Negotiated Rate |
$562.65 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
|
|
BAL STER 6x20x135cm39031-60201
|
Facility
|
OP
|
$2,325.00
|
|
| Hospital Charge Code |
270637715V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.03 |
| Max. Negotiated Rate |
$1,162.50 |
| Rate for Payer: Aetna Commercial |
$883.50
|
| Rate for Payer: Aetna Medicare Advantage |
$697.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$592.88
|
| Rate for Payer: Cigna Commercial |
$1,162.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$56.03
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$61.61
|
|
|
BAL STERL 4x20x80 39031-40208
|
Facility
|
IP
|
$2,325.00
|
|
| Hospital Charge Code |
270637555V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.75 |
| Max. Negotiated Rate |
$562.65 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
|
|
BAL STERL 4x20x80 39031-40208
|
Facility
|
OP
|
$2,325.00
|
|
| Hospital Charge Code |
270637555V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.03 |
| Max. Negotiated Rate |
$1,162.50 |
| Rate for Payer: Aetna Commercial |
$883.50
|
| Rate for Payer: Aetna Medicare Advantage |
$697.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$592.88
|
| Rate for Payer: Cigna Commercial |
$1,162.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$56.03
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$61.61
|
|
|
BAL STERL 5x20x80 39031-50208
|
Facility
|
OP
|
$2,325.00
|
|
| Hospital Charge Code |
270637556V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$56.03 |
| Max. Negotiated Rate |
$1,162.50 |
| Rate for Payer: Aetna Commercial |
$883.50
|
| Rate for Payer: Aetna Medicare Advantage |
$697.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$592.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$592.88
|
| Rate for Payer: Cigna Commercial |
$1,162.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$56.03
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$61.61
|
|
|
BAL STERL 5x20x80 39031-50208
|
Facility
|
IP
|
$2,325.00
|
|
| Hospital Charge Code |
270637556V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.75 |
| Max. Negotiated Rate |
$562.65 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$465.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$562.65
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$511.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$348.75
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$1,548.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3190M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$232.20 |
| Max. Negotiated Rate |
$232.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$232.20
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3080M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$337.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3034M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$337.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3237M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$337.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3080M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$54.23 |
| Max. Negotiated Rate |
$1,125.00 |
| Rate for Payer: Aetna Commercial |
$855.00
|
| Rate for Payer: Aetna Medicare Advantage |
$675.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$573.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$573.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$573.75
|
| Rate for Payer: Cigna Commercial |
$1,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$675.00
|
| Rate for Payer: Oxford Commercial |
$91.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$159.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$54.23
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$59.62
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3120M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$337.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3037M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$54.23 |
| Max. Negotiated Rate |
$1,125.00 |
| Rate for Payer: Aetna Commercial |
$855.00
|
| Rate for Payer: Aetna Medicare Advantage |
$675.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$573.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$573.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$573.75
|
| Rate for Payer: Cigna Commercial |
$1,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$675.00
|
| Rate for Payer: Oxford Commercial |
$91.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$337.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$159.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$54.23
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$59.62
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
OP
|
$1,548.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3121M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$774.00 |
| Rate for Payer: Aetna Commercial |
$588.24
|
| Rate for Payer: Aetna Medicare Advantage |
$464.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$394.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$394.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$394.74
|
| Rate for Payer: Cigna Commercial |
$774.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$464.40
|
| Rate for Payer: Oxford Commercial |
$91.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$232.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$159.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$37.31
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$41.02
|
|
|
BAMLAN+ETESEVIMAB INFUS&MONITR
|
Facility
|
IP
|
$1,548.00
|
|
|
Service Code
|
HCPCS M0245
|
| Hospital Charge Code |
3043M0245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$232.20 |
| Max. Negotiated Rate |
$232.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$232.20
|
|
