|
ENDO UNIVERSAL 65 DEG 4.0MM***
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
1605898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$142.80 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$142.80
|
|
|
ENDO UNIVERSAL 65 DEG 4.0MM***
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
1605898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Aetna Commercial |
$285.60
|
| Rate for Payer: Aetna Medicare Advantage |
$285.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$242.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$242.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$242.76
|
| Rate for Payer: Cigna Commercial |
$476.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$123.76
|
| Rate for Payer: Oxford Commercial |
$476.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$142.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$476.00
|
|
|
ENDO UNIVERSAL 65 DEG 4.8MM***
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
1605906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Aetna Commercial |
$285.60
|
| Rate for Payer: Aetna Medicare Advantage |
$285.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$242.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$242.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$242.76
|
| Rate for Payer: Cigna Commercial |
$476.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$123.76
|
| Rate for Payer: Oxford Commercial |
$476.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$142.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$476.00
|
|
|
ENDO UNIVERSAL 65 DEG 4.8MM***
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
1605906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$142.80 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$142.80
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
OP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
7411645
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$565.74 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,347.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,347.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,995.38
|
| Rate for Payer: Cigna Commercial |
$565.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,017.25
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
IP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
2600241
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,173.75 |
| Max. Negotiated Rate |
$1,173.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
IP
|
$4,582.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
5792273
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$687.30 |
| Max. Negotiated Rate |
$687.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$687.30
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
IP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
7411645
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,173.75 |
| Max. Negotiated Rate |
$1,173.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
OP
|
$4,582.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
5792273
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$327.14 |
| Max. Negotiated Rate |
$1,374.60 |
| Rate for Payer: Aetna Commercial |
$1,374.60
|
| Rate for Payer: Aetna Medicare Advantage |
$1,374.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,168.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,168.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$327.14
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,168.41
|
| Rate for Payer: Cigna Commercial |
$565.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$595.66
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$687.30
|
|
|
ENDOVASC IC PR ADM 1ST TERR
|
Facility
|
OP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61650
|
| Hospital Charge Code |
2600241
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$565.74 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,347.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,347.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,995.38
|
| Rate for Payer: Cigna Commercial |
$565.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,017.25
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
OP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
7411646
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$241.97 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,347.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,347.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,995.38
|
| Rate for Payer: Cigna Commercial |
$241.97
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,017.25
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
IP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
2600242
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,173.75 |
| Max. Negotiated Rate |
$1,173.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
IP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
7411646
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,173.75 |
| Max. Negotiated Rate |
$1,173.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
OP
|
$4,582.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
5792274
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$138.93 |
| Max. Negotiated Rate |
$1,374.60 |
| Rate for Payer: Aetna Commercial |
$1,374.60
|
| Rate for Payer: Aetna Medicare Advantage |
$1,374.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,168.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,168.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$138.93
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,168.41
|
| Rate for Payer: Cigna Commercial |
$241.97
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$595.66
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$687.30
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
IP
|
$4,582.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
5792274
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$687.30 |
| Max. Negotiated Rate |
$687.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$687.30
|
|
|
ENDOVASC IC PR ADM EA ADD TERR
|
Facility
|
OP
|
$7,825.00
|
|
|
Service Code
|
HCPCS 61651
|
| Hospital Charge Code |
2600242
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$241.97 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,347.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,347.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,995.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,995.38
|
| Rate for Payer: Cigna Commercial |
$241.97
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,017.25
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,173.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
OP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
7411390
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,165.74 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,871.89
|
| Rate for Payer: Aetna Medicare Advantage |
$2,871.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,441.10
|
| Rate for Payer: Cigna Commercial |
$1,165.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,244.48
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
IP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
321033881
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,435.94 |
| Max. Negotiated Rate |
$1,435.94 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
OP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
321033881
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,165.74 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,871.89
|
| Rate for Payer: Aetna Medicare Advantage |
$2,871.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,441.10
|
| Rate for Payer: Cigna Commercial |
$1,165.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,244.48
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
IP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
7411390
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,435.94 |
| Max. Negotiated Rate |
$1,435.94 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
IP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
5701112
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,435.94 |
| Max. Negotiated Rate |
$1,435.94 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
|
|
ENDOVASC TAA REPR W/O SUBCL
|
Facility
|
OP
|
$9,572.95
|
|
|
Service Code
|
HCPCS 33881
|
| Hospital Charge Code |
5701112
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,165.74 |
| Max. Negotiated Rate |
$6,873.00 |
| Rate for Payer: Aetna Commercial |
$2,871.89
|
| Rate for Payer: Aetna Medicare Advantage |
$2,871.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,441.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,441.10
|
| Rate for Payer: Cigna Commercial |
$1,165.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,244.48
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,435.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
ENDOVASC TEMPORY VESSEL OCCL
|
Facility
|
IP
|
$61,620.70
|
|
|
Service Code
|
HCPCS 61623
|
| Hospital Charge Code |
411061623
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$9,243.10 |
| Max. Negotiated Rate |
$9,243.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$9,243.10
|
|
|
ENDOVASC TEMPORY VESSEL OCCL
|
Facility
|
OP
|
$61,620.70
|
|
|
Service Code
|
HCPCS 61623
|
| Hospital Charge Code |
411061623
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$27,491.26 |
| Rate for Payer: Aetna Commercial |
$18,486.21
|
| Rate for Payer: Aetna Medicare Advantage |
$18,486.21
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15,713.28
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15,713.28
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15,713.28
|
| Rate for Payer: Cigna Commercial |
$27,491.26
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8,010.69
|
| Rate for Payer: Oxford Commercial |
$9,689.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$9,243.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$10,997.00
|
|
|
ENDOVASC TEMPORY VESSEL OCCL
|
Facility
|
IP
|
$61,620.70
|
|
|
Service Code
|
HCPCS 61623
|
| Hospital Charge Code |
366861623
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$9,243.10 |
| Max. Negotiated Rate |
$9,243.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$9,243.10
|
|
