|
GRAFT ZEN AAA MN BODY TFB28117
|
Facility
|
OP
|
$36,704.00
|
|
| Hospital Charge Code |
270634073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,505.60 |
| Max. Negotiated Rate |
$18,352.00 |
| Rate for Payer: Aetna Commercial |
$11,011.20
|
| Rate for Payer: Aetna Medicare Advantage |
$11,011.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$9,359.52
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$9,359.52
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$7,340.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$9,359.52
|
| Rate for Payer: Cigna Commercial |
$18,352.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8,882.37
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$5,505.60
|
|
|
GRAFT ZEN AAA MN BODY TFB28117
|
Facility
|
IP
|
$36,704.00
|
|
| Hospital Charge Code |
270634073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,505.60 |
| Max. Negotiated Rate |
$8,882.37 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$7,340.80
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8,882.37
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$5,505.60
|
|
|
GRAFT ZEN FLX AAA EXT ESBE2658
|
Facility
|
IP
|
$9,435.00
|
|
| Hospital Charge Code |
270643454V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.25 |
| Max. Negotiated Rate |
$2,283.27 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,887.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,283.27
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,415.25
|
|
|
GRAFT ZEN FLX AAA EXT ESBE2658
|
Facility
|
OP
|
$9,435.00
|
|
| Hospital Charge Code |
270643454V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,415.25 |
| Max. Negotiated Rate |
$4,717.50 |
| Rate for Payer: Aetna Commercial |
$2,830.50
|
| Rate for Payer: Aetna Medicare Advantage |
$2,830.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,405.93
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,405.93
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,887.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,405.93
|
| Rate for Payer: Cigna Commercial |
$4,717.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,283.27
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,415.25
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
OP
|
$13,905.00
|
|
| Hospital Charge Code |
270635150
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,085.75 |
| Max. Negotiated Rate |
$6,952.50 |
| Rate for Payer: Aetna Commercial |
$4,171.50
|
| Rate for Payer: Aetna Medicare Advantage |
$4,171.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,545.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,545.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,781.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,545.78
|
| Rate for Payer: Cigna Commercial |
$6,952.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,365.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,085.75
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
IP
|
$14,320.00
|
|
| Hospital Charge Code |
270635151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,148.00 |
| Max. Negotiated Rate |
$3,465.44 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,864.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,465.44
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,148.00
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
IP
|
$13,905.00
|
|
| Hospital Charge Code |
270635150
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,085.75 |
| Max. Negotiated Rate |
$3,365.01 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,781.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,365.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,085.75
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642910
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
OP
|
$14,320.00
|
|
| Hospital Charge Code |
270635151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,148.00 |
| Max. Negotiated Rate |
$7,160.00 |
| Rate for Payer: Aetna Commercial |
$4,296.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,296.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,651.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,651.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,651.60
|
| Rate for Payer: Cigna Commercial |
$7,160.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,465.44
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,148.00
|
|
|
GRAFT ZENITH AAA ILIAC LEG
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642910
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXT
|
Facility
|
OP
|
$13,392.00
|
|
| Hospital Charge Code |
270636179
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,008.80 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$4,017.60
|
| Rate for Payer: Aetna Medicare Advantage |
$4,017.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,414.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,414.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,678.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,414.96
|
| Rate for Payer: Cigna Commercial |
$6,696.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,240.86
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,008.80
|
|
|
GRAFT ZENITH AAA LEG EXT
|
Facility
|
IP
|
$13,392.00
|
|
| Hospital Charge Code |
270636179
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,008.80 |
| Max. Negotiated Rate |
$3,240.86 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,678.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,240.86
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,008.80
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$14,320.00
|
|
| Hospital Charge Code |
270639809
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,148.00 |
| Max. Negotiated Rate |
$7,160.00 |
| Rate for Payer: Aetna Commercial |
$4,296.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,296.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,651.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,651.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,864.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,651.60
|
| Rate for Payer: Cigna Commercial |
$7,160.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,465.44
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,148.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
IP
|
$14,980.00
|
|
| Hospital Charge Code |
270642396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$3,625.16 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
IP
|
$14,320.00
|
|
| Hospital Charge Code |
270639809
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,148.00 |
| Max. Negotiated Rate |
$3,465.44 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,864.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,465.44
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,148.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$13,392.00
|
|
| Hospital Charge Code |
270636178
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,008.80 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$4,017.60
|
| Rate for Payer: Aetna Medicare Advantage |
$4,017.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,414.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,414.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,678.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,414.96
|
| Rate for Payer: Cigna Commercial |
$6,696.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,240.86
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,008.80
|
|
|
GRAFT ZENITH AAA LEG EXTENSION
|
Facility
|
OP
|
$14,980.00
|
|
| Hospital Charge Code |
270642396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.00 |
| Max. Negotiated Rate |
$7,490.00 |
| Rate for Payer: Aetna Commercial |
$4,494.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,494.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,819.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,996.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,819.90
|
| Rate for Payer: Cigna Commercial |
$7,490.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,625.16
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,247.00
|
|