|
COMPNT ZIM FEM RT SZ F 5972162
|
Facility
|
OP
|
$15,497.50
|
|
| Hospital Charge Code |
270607283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,324.62 |
| Max. Negotiated Rate |
$7,748.75 |
| Rate for Payer: Aetna Commercial |
$4,649.25
|
| Rate for Payer: Aetna Medicare Advantage |
$4,649.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,951.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,951.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,099.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,951.86
|
| Rate for Payer: Cigna Commercial |
$7,748.75
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,750.39
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,324.62
|
|
|
COMPNT ZIM FEM RT SZ F 5972162
|
Facility
|
IP
|
$15,497.50
|
|
| Hospital Charge Code |
270607283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,324.62 |
| Max. Negotiated Rate |
$3,750.39 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,099.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,750.39
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,324.62
|
|
|
COMPNT ZIM FEM RT SZ G 5972172
|
Facility
|
OP
|
$14,213.75
|
|
| Hospital Charge Code |
270606475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,132.06 |
| Max. Negotiated Rate |
$7,106.88 |
| Rate for Payer: Aetna Commercial |
$4,264.12
|
| Rate for Payer: Aetna Medicare Advantage |
$4,264.12
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,624.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,624.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,842.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,624.51
|
| Rate for Payer: Cigna Commercial |
$7,106.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,439.73
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,132.06
|
|
|
COMPNT ZIM FEM RT SZ G 5972172
|
Facility
|
IP
|
$14,213.75
|
|
| Hospital Charge Code |
270606475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,132.06 |
| Max. Negotiated Rate |
$3,439.73 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,842.75
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,439.73
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,132.06
|
|
|
COMPNT ZIM FEM SZ 5982132
|
Facility
|
IP
|
$12,905.00
|
|
| Hospital Charge Code |
270611705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,935.75 |
| Max. Negotiated Rate |
$3,123.01 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,581.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,123.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,935.75
|
|
|
COMPNT ZIM FEM SZ 5982132
|
Facility
|
OP
|
$12,905.00
|
|
| Hospital Charge Code |
270611705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,935.75 |
| Max. Negotiated Rate |
$6,452.50 |
| Rate for Payer: Aetna Commercial |
$3,871.50
|
| Rate for Payer: Aetna Medicare Advantage |
$3,871.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,290.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,290.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,581.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,290.78
|
| Rate for Payer: Cigna Commercial |
$6,452.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,123.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,935.75
|
|
|
COMPNT ZIM TIB SZ 2 59802702
|
Facility
|
OP
|
$4,919.25
|
|
| Hospital Charge Code |
270616331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.89 |
| Max. Negotiated Rate |
$2,459.62 |
| Rate for Payer: Aetna Commercial |
$1,475.78
|
| Rate for Payer: Aetna Medicare Advantage |
$1,475.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,254.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,254.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$983.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,254.41
|
| Rate for Payer: Cigna Commercial |
$2,459.62
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,190.46
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$737.89
|
|
|
COMPNT ZIM TIB SZ 2 59802702
|
Facility
|
IP
|
$4,919.25
|
|
| Hospital Charge Code |
270616331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.89 |
| Max. Negotiated Rate |
$1,190.46 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$983.85
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,190.46
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$737.89
|
|
|
COMPNT ZIM TIB SZ 5 598805
|
Facility
|
IP
|
$5,529.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270625220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$829.45 |
| Max. Negotiated Rate |
$1,338.18 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,105.93
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,338.18
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$829.45
|
|
|
COMPNT ZIM TIB SZ 5 598805
|
Facility
|
OP
|
$5,529.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270625220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$829.45 |
| Max. Negotiated Rate |
$2,764.82 |
| Rate for Payer: Aetna Commercial |
$1,658.89
|
| Rate for Payer: Aetna Medicare Advantage |
$1,658.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,410.06
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,410.06
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,105.93
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,410.06
|
| Rate for Payer: Cigna Commercial |
$2,764.82
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,338.18
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$829.45
|
|
|
COMPNT ZIM TIB SZ 6 59804702
|
Facility
|
IP
|
$8,337.95
|
|
| Hospital Charge Code |
270607284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.69 |
| Max. Negotiated Rate |
$2,017.78 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,667.59
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,017.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,250.69
|
|
|
COMPNT ZIM TIB SZ 6 59804702
|
Facility
|
OP
|
$8,337.95
|
|
| Hospital Charge Code |
270607284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.69 |
| Max. Negotiated Rate |
$4,168.98 |
| Rate for Payer: Aetna Commercial |
$2,501.39
|
| Rate for Payer: Aetna Medicare Advantage |
$2,501.39
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,126.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,126.18
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,667.59
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,126.18
|
| Rate for Payer: Cigna Commercial |
$4,168.98
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,017.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,250.69
|
|
|
COMPONENT FEMORAL CEMN SZ22 RT
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMN SZ22 RT
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ1+
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270680559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ1+
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270680559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ 3 L
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270684046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ 3 L
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270684046
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ3+ R
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ3+ R
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ3 RT
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ3 RT
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ4+ R
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ4+ R
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|
|
COMPONENT FEMORAL CEMTD SZ6 RT
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270677520
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$2,400.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,040.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,600.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$4,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,936.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,200.00
|
|