|
FEMUR BONE
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
270671826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$150.00
|
| Rate for Payer: Aetna Medicare Advantage |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$127.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$127.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$100.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$127.50
|
| Rate for Payer: Cigna Commercial |
$250.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$121.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$75.00
|
|
|
FEMUR BONE
|
Facility
|
IP
|
$500.00
|
|
| Hospital Charge Code |
270671826
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$121.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$100.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$121.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$75.00
|
|
|
FEMUR BONE MODEL LEFT
|
Facility
|
IP
|
$500.00
|
|
| Hospital Charge Code |
270673960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$75.00
|
|
|
FEMUR BONE MODEL LEFT
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
270673960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$150.00
|
| Rate for Payer: Aetna Medicare Advantage |
$150.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$127.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$127.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$127.50
|
| Rate for Payer: Cigna Commercial |
$250.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$65.00
|
| Rate for Payer: Oxford Commercial |
$250.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$75.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$250.00
|
|
|
FEMUR CEMENTED RIGHT SZ 6 STD
|
Facility
|
IP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270689504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$2,420.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
FEMUR CEMENTED RIGHT SZ 6 STD
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270689504
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Commercial |
$3,000.00
|
| Rate for Payer: Aetna Medicare Advantage |
$3,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,550.00
|
| Rate for Payer: Cigna Commercial |
$5,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
FEMUR CEMENTED STD SZ 9
|
Facility
|
OP
|
$53,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270699093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,982.25 |
| Max. Negotiated Rate |
$26,607.50 |
| Rate for Payer: Aetna Commercial |
$15,964.50
|
| Rate for Payer: Aetna Medicare Advantage |
$15,964.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$13,569.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$13,569.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$10,643.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$13,569.83
|
| Rate for Payer: Cigna Commercial |
$26,607.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$12,878.03
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$7,982.25
|
|
|
FEMUR CEMENTED STD SZ 9
|
Facility
|
IP
|
$53,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270699093
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,982.25 |
| Max. Negotiated Rate |
$12,878.03 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$10,643.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$12,878.03
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$7,982.25
|
|
|
FEMUR CEMENTED STD SZ 9 LEFT
|
Facility
|
IP
|
$53,215.00
|
|
| Hospital Charge Code |
270702033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,982.25 |
| Max. Negotiated Rate |
$12,878.03 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$10,643.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$12,878.03
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$7,982.25
|
|
|
FEMUR CEMENTED STD SZ 9 LEFT
|
Facility
|
OP
|
$53,215.00
|
|
| Hospital Charge Code |
270702033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,982.25 |
| Max. Negotiated Rate |
$26,607.50 |
| Rate for Payer: Aetna Commercial |
$15,964.50
|
| Rate for Payer: Aetna Medicare Advantage |
$15,964.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$13,569.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$13,569.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$10,643.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$13,569.83
|
| Rate for Payer: Cigna Commercial |
$26,607.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$12,878.03
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$7,982.25
|
|
|
FEMUR COMPONENT
|
Facility
|
OP
|
$12,166.15
|
|
| Hospital Charge Code |
270657025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.92 |
| Max. Negotiated Rate |
$6,083.07 |
| Rate for Payer: Aetna Commercial |
$3,649.84
|
| Rate for Payer: Aetna Medicare Advantage |
$3,649.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,102.37
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,102.37
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,433.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,102.37
|
| Rate for Payer: Cigna Commercial |
$6,083.07
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,944.21
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,824.92
|
|
|
FEMUR COMPONENT
|
Facility
|
IP
|
$12,166.15
|
|
| Hospital Charge Code |
270657025
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,824.92 |
| Max. Negotiated Rate |
$2,944.21 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,433.23
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,944.21
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,824.92
|
|
|
FEMUR CR INTERLOC 62.5R 183006
|
Facility
|
OP
|
$14,620.00
|
|
| Hospital Charge Code |
270640105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,193.00 |
| Max. Negotiated Rate |
$7,310.00 |
| Rate for Payer: Aetna Commercial |
$4,386.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,386.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,728.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,728.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,924.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,728.10
|
| Rate for Payer: Cigna Commercial |
$7,310.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,538.04
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,193.00
|
|
|
FEMUR CR INTERLOC 62.5R 183006
|
Facility
|
IP
|
$14,620.00
|
|
| Hospital Charge Code |
270640105
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,193.00 |
| Max. Negotiated Rate |
$3,538.04 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,924.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,538.04
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,193.00
|
|
|
FEMUR CR PORO 62.5MM RT 183046
|
Facility
|
OP
|
$17,420.00
|
|
| Hospital Charge Code |
270640576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,613.00 |
| Max. Negotiated Rate |
$8,710.00 |
| Rate for Payer: Aetna Commercial |
$5,226.00
|
| Rate for Payer: Aetna Medicare Advantage |
$5,226.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4,442.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4,442.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,484.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$4,442.10
|
| Rate for Payer: Cigna Commercial |
$8,710.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,215.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,613.00
|
|
|
FEMUR CR PORO 62.5MM RT 183046
|
Facility
|
IP
|
$17,420.00
|
|
| Hospital Charge Code |
270640576
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,613.00 |
| Max. Negotiated Rate |
$4,215.64 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,484.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,215.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,613.00
|
|
|
FEMUR CR POROUS 65MM RT 183043
|
Facility
|
IP
|
$17,420.00
|
|
| Hospital Charge Code |
270640543
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,613.00 |
| Max. Negotiated Rate |
$4,215.64 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,484.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,215.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,613.00
|
|
|
FEMUR CR POROUS 65MM RT 183043
|
Facility
|
OP
|
$17,420.00
|
|
| Hospital Charge Code |
270640543
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,613.00 |
| Max. Negotiated Rate |
$8,710.00 |
| Rate for Payer: Aetna Commercial |
$5,226.00
|
| Rate for Payer: Aetna Medicare Advantage |
$5,226.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4,442.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4,442.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,484.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$4,442.10
|
| Rate for Payer: Cigna Commercial |
$8,710.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,215.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,613.00
|
|
|
FEMUR CUTTING BLOCK FEMUR CUTT
|
Facility
|
OP
|
$625.00
|
|
| Hospital Charge Code |
270678756
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$312.50 |
| Rate for Payer: Aetna Commercial |
$187.50
|
| Rate for Payer: Aetna Medicare Advantage |
$187.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$159.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$159.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$159.38
|
| Rate for Payer: Cigna Commercial |
$312.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$81.25
|
| Rate for Payer: Oxford Commercial |
$312.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$93.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$312.50
|
|
|
FEMUR CUTTING BLOCK FEMUR CUTT
|
Facility
|
IP
|
$625.00
|
|
| Hospital Charge Code |
270678756
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.75 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$93.75
|
|
|
FEMUR CUTTING BLOCK LF SZ 3
|
Facility
|
OP
|
$2,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270671829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$1,312.50 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Aetna Medicare Advantage |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$669.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$669.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$525.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$669.38
|
| Rate for Payer: Cigna Commercial |
$1,312.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$635.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$393.75
|
|
|
FEMUR CUTTING BLOCK LF SZ 3
|
Facility
|
IP
|
$2,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
270671829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$635.25 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$525.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$635.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$393.75
|
|
|
FEMUR CUTTING BLOCK RT SZ 3
|
Facility
|
OP
|
$2,625.00
|
|
| Hospital Charge Code |
270672253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$1,312.50 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Aetna Medicare Advantage |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$669.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$669.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$525.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$669.38
|
| Rate for Payer: Cigna Commercial |
$1,312.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$635.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$393.75
|
|
|
FEMUR CUTTING BLOCK RT SZ 3
|
Facility
|
IP
|
$2,625.00
|
|
| Hospital Charge Code |
270672253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$635.25 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$525.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$635.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$393.75
|
|
|
FEMUR CUTTING BLOCK RT SZ4
|
Facility
|
IP
|
$2,625.00
|
|
| Hospital Charge Code |
270675308
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$393.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$393.75
|
|