|
CATH PTA LUTONIX 4.0x150x130CM
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 4.0x150x130CM
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678932S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 4.0x150x130CM
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678932S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 5X120M 120CM
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 5X120M 120CM
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678933
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 5X300MM 100CM
|
Facility
|
IP
|
$13,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270695612C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,062.50 |
| Max. Negotiated Rate |
$3,327.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,750.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,327.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,062.50
|
|
|
CATH PTA LUTONIX 5X300MM 100CM
|
Facility
|
OP
|
$13,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270695612C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,062.50 |
| Max. Negotiated Rate |
$6,875.00 |
| Rate for Payer: Aetna Commercial |
$4,125.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,125.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,506.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,506.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,750.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,506.25
|
| Rate for Payer: Cigna Commercial |
$6,875.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,327.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,062.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678935S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
IP
|
$9,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678934S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,462.50 |
| Max. Negotiated Rate |
$2,359.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,950.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,359.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,462.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
IP
|
$9,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,462.50 |
| Max. Negotiated Rate |
$2,359.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,950.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,359.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,462.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678935S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
OP
|
$9,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,462.50 |
| Max. Negotiated Rate |
$4,875.00 |
| Rate for Payer: Aetna Commercial |
$2,925.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,925.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,486.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,486.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,950.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,486.25
|
| Rate for Payer: Cigna Commercial |
$4,875.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,359.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,462.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 6.0x120x130cm
|
Facility
|
OP
|
$9,750.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678934S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,462.50 |
| Max. Negotiated Rate |
$4,875.00 |
| Rate for Payer: Aetna Commercial |
$2,925.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,925.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,486.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,486.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,950.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,486.25
|
| Rate for Payer: Cigna Commercial |
$4,875.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,359.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,462.50
|
|
|
CATH PTA LUTONIX 70x40x130cm
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 70x40x130cm
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 7.0x60x130cm
|
Facility
|
OP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$4,125.00 |
| Rate for Payer: Aetna Commercial |
$2,475.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,103.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,103.75
|
| Rate for Payer: Cigna Commercial |
$4,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA LUTONIX 7.0x60x130cm
|
Facility
|
IP
|
$8,250.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
270678946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.50 |
| Max. Negotiated Rate |
$1,996.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,650.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,996.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,237.50
|
|
|
CATH PTA SAILOR PLUS 6x120x13
|
Facility
|
OP
|
$1,767.00
|
|
| Hospital Charge Code |
270635527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$229.71 |
| Max. Negotiated Rate |
$883.50 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Medicare Advantage |
$530.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$450.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$450.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$450.58
|
| Rate for Payer: Cigna Commercial |
$883.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$229.71
|
| Rate for Payer: Oxford Commercial |
$883.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$265.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$883.50
|
|
|
CATH PTA SAILOR PLUS 6x120x13
|
Facility
|
IP
|
$1,767.00
|
|
| Hospital Charge Code |
270635527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$265.05 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$265.05
|
|
|
CATH PUNUMB 5MAX DISTAL 115CM
|
Facility
|
IP
|
$7,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270696885S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,117.50 |
| Max. Negotiated Rate |
$1,802.90 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,802.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,117.50
|
|
|
CATH PUNUMB 5MAX DISTAL 115CM
|
Facility
|
OP
|
$7,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270696885S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,117.50 |
| Max. Negotiated Rate |
$3,725.00 |
| Rate for Payer: Aetna Commercial |
$2,235.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,235.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,899.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,899.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,490.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,899.75
|
| Rate for Payer: Cigna Commercial |
$3,725.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,802.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,117.50
|
|
|
CATH PWERFLEX 5x4 80c 4205040S
|
Facility
|
OP
|
$1,314.45
|
|
| Hospital Charge Code |
270630176
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$197.17 |
| Max. Negotiated Rate |
$657.23 |
| Rate for Payer: Aetna Commercial |
$394.33
|
| Rate for Payer: Aetna Medicare Advantage |
$394.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$335.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$335.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$262.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$335.18
|
| Rate for Payer: Cigna Commercial |
$657.23
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$318.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$197.17
|
|
|
CATH PWERFLEX 5x4 80c 4205040S
|
Facility
|
IP
|
$1,314.45
|
|
| Hospital Charge Code |
270630176
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$197.17 |
| Max. Negotiated Rate |
$318.10 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$262.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$318.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$197.17
|
|
