|
STENT RX XP 2.25X18 1074225-18
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658754C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.25X23 1074225-23
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658755C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.25X23 1074225-23
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658755C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.25X28 1074225-28
|
Facility
|
OP
|
$7,000.00
|
|
| Hospital Charge Code |
270658756C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.25X28 1074225-28
|
Facility
|
IP
|
$7,000.00
|
|
| Hospital Charge Code |
270658756C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X08 1074250-08
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658757C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X08 1074250-08
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658757C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X12 1074250-12
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658758C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X12 1074250-12
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658758C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X15 1074250-15
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658759C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X15 1074250-15
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658759C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X18 1074250-18
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658760C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X18 1074250-18
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658760C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X23 1074250-23
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658761C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X23 1074250-23
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658761C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X28 1074250-28
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658762C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X28 1074250-28
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658762C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X33 1074250-33
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658763C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.5X33 1074250-33
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658763C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X38 1074250-38
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658764C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.5X38 1074250-38
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658764C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.75X08 1074275-08
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658765C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
|
STENT RX XP 2.75X08 1074275-08
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658765C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.75X12 1074275-12
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658766C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.70 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,660.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,785.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,785.00
|
| Rate for Payer: Cigna Commercial |
$3,500.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$168.70
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$185.50
|
|
|
STENT RX XP 2.75X12 1074275-12
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
270658766C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$1,694.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,400.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,694.00
|
| Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan |
$1,540.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,050.00
|
|
