|
INJ PARAVERT F JNT L/S 3-LEV
|
Facility
|
IP
|
$6,666.60
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
1600000431
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$999.99 |
| Max. Negotiated Rate |
$999.99 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$999.99
|
|
|
INJ PARAVERT F JNT L/S 3-LEV
|
Facility
|
OP
|
$6,666.60
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
411064495
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$48.88 |
| Max. Negotiated Rate |
$1,999.98 |
| Rate for Payer: Aetna Commercial |
$1,999.98
|
| Rate for Payer: Aetna Medicare Advantage |
$1,999.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,699.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,699.98
|
| 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 |
$1,699.98
|
| Rate for Payer: Cigna Commercial |
$48.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$866.66
|
| Rate for Payer: Oxford Commercial |
$1,487.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$999.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,686.00
|
|
|
INJ PARAVERT F JNT L/S 3-LEV
|
Facility
|
OP
|
$6,666.60
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
1600000431
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$48.88 |
| Max. Negotiated Rate |
$1,999.98 |
| Rate for Payer: Aetna Commercial |
$1,999.98
|
| Rate for Payer: Aetna Medicare Advantage |
$1,999.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,699.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,699.98
|
| 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 |
$1,699.98
|
| Rate for Payer: Cigna Commercial |
$48.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$866.66
|
| Rate for Payer: Oxford Commercial |
$1,487.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$999.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,686.00
|
|
|
INJ PARAVERT F JNT L/S 3-LEV
|
Facility
|
IP
|
$6,666.60
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
411064495
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$999.99 |
| Max. Negotiated Rate |
$999.99 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$999.99
|
|
|
INJ PROC AORTOGRAPHY
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
366893567
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$61.20
|
|
|
INJ PROC AORTOGRAPHY
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
7411247
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$34.89 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Aetna Medicare Advantage |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$4,350.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$104.04
|
| Rate for Payer: Cigna Commercial |
$34.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$53.04
|
| Rate for Payer: Oxford Commercial |
$1,487.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$61.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,686.00
|
|
|
INJ PROC AORTOGRAPHY
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
7411247
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$61.20
|
|
|
INJ PROC AORTOGRAPHY
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
366893567
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$34.89 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Aetna Medicare Advantage |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$4,350.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$104.04
|
| Rate for Payer: Cigna Commercial |
$34.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$53.04
|
| Rate for Payer: Oxford Commercial |
$1,487.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$61.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,686.00
|
|
|
INJ PSEUDOANEURYSM
|
Facility
|
OP
|
$1,133.35
|
|
|
Service Code
|
HCPCS 36002
|
| Hospital Charge Code |
5100826
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$147.34 |
| Max. Negotiated Rate |
$2,575.00 |
| Rate for Payer: Aetna Commercial |
$340.00
|
| Rate for Payer: Aetna Medicare Advantage |
$340.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$289.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$289.00
|
| 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 |
$289.00
|
| Rate for Payer: Cigna Commercial |
$1,493.86
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$147.34
|
| Rate for Payer: Oxford Commercial |
$2,269.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$170.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,575.00
|
|
|
INJ PSEUDOANEURYSM
|
Facility
|
IP
|
$1,133.35
|
|
|
Service Code
|
HCPCS 36002
|
| Hospital Charge Code |
5100826
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$170.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$170.00
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
OP
|
$2,072.24
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
7411560
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$269.39 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$621.67
|
| Rate for Payer: Aetna Medicare Advantage |
$621.67
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$528.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$528.42
|
| 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 |
$528.42
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$269.39
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
IP
|
$14,313.70
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
2600222
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,147.05 |
| Max. Negotiated Rate |
$2,147.05 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,147.05
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
IP
|
$2,072.24
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
7411560
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$310.84 |
| Max. Negotiated Rate |
$310.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.84
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
OP
|
$2,072.24
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
2011599
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$269.39 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$621.67
|
| Rate for Payer: Aetna Medicare Advantage |
$621.67
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$528.42
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$528.42
|
| 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 |
$528.42
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$269.39
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
IP
|
$2,072.24
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
2011599
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$310.84 |
| Max. Negotiated Rate |
$310.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.84
|
|
|
INJ PX CHOLANG EXISTING ACCESS
|
Facility
|
OP
|
$14,313.70
|
|
|
Service Code
|
HCPCS 47531
|
| Hospital Charge Code |
2600222
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,860.78 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$4,294.11
|
| Rate for Payer: Aetna Medicare Advantage |
$4,294.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,649.99
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,649.99
|
| 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 |
$3,649.99
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,860.78
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,147.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
IP
|
$12,827.31
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
2011563
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,924.10 |
| Max. Negotiated Rate |
$1,924.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,924.10
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
OP
|
$12,827.31
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
7411561
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,667.55 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$3,848.19
|
| Rate for Payer: Aetna Medicare Advantage |
$3,848.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,270.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,270.96
|
| 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 |
$3,270.96
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,667.55
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,924.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
OP
|
$18,206.00
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
2600223
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$5,461.80
|
| Rate for Payer: Aetna Medicare Advantage |
$5,461.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4,642.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4,642.53
|
| 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 |
$4,642.53
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,366.78
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,730.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
IP
|
$18,206.00
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
2600223
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,730.90 |
| Max. Negotiated Rate |
$2,730.90 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,730.90
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
OP
|
$12,827.31
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
2011563
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,667.55 |
| Max. Negotiated Rate |
$8,526.35 |
| Rate for Payer: Aetna Commercial |
$3,848.19
|
| Rate for Payer: Aetna Medicare Advantage |
$3,848.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,270.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,270.96
|
| 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 |
$3,270.96
|
| Rate for Payer: Cigna Commercial |
$8,526.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,667.55
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,924.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
INJ PX CHOLANG NEW ACCESS
|
Facility
|
IP
|
$12,827.31
|
|
|
Service Code
|
HCPCS 47532
|
| Hospital Charge Code |
7411561
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,924.10 |
| Max. Negotiated Rate |
$1,924.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,924.10
|
|
|
INJ PX SACROILIAC W IMAGE/ARTH
|
Facility
|
OP
|
$3,185.50
|
|
|
Service Code
|
HCPCS 27096
|
| Hospital Charge Code |
420827096
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$80.53 |
| Max. Negotiated Rate |
$1,864.00 |
| Rate for Payer: Aetna Commercial |
$955.65
|
| Rate for Payer: Aetna Medicare Advantage |
$955.65
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$812.30
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$812.30
|
| 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 |
$812.30
|
| Rate for Payer: Cigna Commercial |
$80.53
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$414.12
|
| Rate for Payer: Oxford Commercial |
$1,487.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$477.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,686.00
|
|
|
INJ PX SACROILIAC W IMAGE/ARTH
|
Facility
|
IP
|
$3,185.50
|
|
|
Service Code
|
HCPCS 27096
|
| Hospital Charge Code |
420827096
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$477.82 |
| Max. Negotiated Rate |
$477.82 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$477.82
|
|
|
INJ.SCLEROSING SOL.SINGLE VEIN
|
Facility
|
OP
|
$623.14
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
75190140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$968.07 |
| Rate for Payer: Aetna Commercial |
$186.94
|
| Rate for Payer: Aetna Medicare Advantage |
$186.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$158.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$158.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$158.90
|
| Rate for Payer: Cigna Commercial |
$968.07
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$81.01
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$93.47
|
|
