|
IR-REPL EXT URET STENT-RT
|
Facility
|
OP
|
$4,540.00
|
|
|
Service Code
|
HCPCS 50387RT
|
| Hospital Charge Code |
7411963
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$590.20 |
| Max. Negotiated Rate |
$2,270.00 |
| Rate for Payer: Aetna Commercial |
$1,362.00
|
| Rate for Payer: Aetna Medicare Advantage |
$1,362.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,157.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,157.70
|
| 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 |
$1,157.70
|
| Rate for Payer: Cigna Commercial |
$2,270.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$590.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$681.00
|
|
|
IR-REPL EXT URET STENT-RT
|
Facility
|
OP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 50387RT
|
| Hospital Charge Code |
411050387R
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,324.41 |
| Max. Negotiated Rate |
$5,093.90 |
| Rate for Payer: Aetna Commercial |
$3,056.34
|
| Rate for Payer: Aetna Medicare Advantage |
$3,056.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,597.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,597.89
|
| 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 |
$2,597.89
|
| Rate for Payer: Cigna Commercial |
$5,093.90
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,324.41
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
|
|
IR-REPL EXT URET STENT-RT
|
Facility
|
IP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 50387RT
|
| Hospital Charge Code |
2691575
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,528.17 |
| Max. Negotiated Rate |
$1,528.17 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
|
|
IR-REPL EXT URET STENT-RT
|
Facility
|
IP
|
$10,187.80
|
|
|
Service Code
|
HCPCS 50387RT
|
| Hospital Charge Code |
321050387R
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,528.17 |
| Max. Negotiated Rate |
$1,528.17 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,528.17
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
IP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
7411599
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$653.84 |
| Max. Negotiated Rate |
$653.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
IP
|
$1,891.00
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
2690170
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$283.65 |
| Max. Negotiated Rate |
$283.65 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$283.65
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
OP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
7411599
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$566.66 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$1,307.68
|
| Rate for Payer: Aetna Medicare Advantage |
$1,307.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,111.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,111.53
|
| 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 |
$1,111.53
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$566.66
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
OP
|
$1,891.00
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
2690170
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$245.83 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$567.30
|
| Rate for Payer: Aetna Medicare Advantage |
$567.30
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$482.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$482.20
|
| 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 |
$482.20
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$245.83
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$283.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
OP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
366849452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$566.66 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$1,307.68
|
| Rate for Payer: Aetna Medicare Advantage |
$1,307.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,111.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,111.53
|
| 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 |
$1,111.53
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$566.66
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR-REPL G-J TUBE W/FLUORO
|
Facility
|
IP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49452
|
| Hospital Charge Code |
366849452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$653.84 |
| Max. Negotiated Rate |
$653.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
OP
|
$4,397.88
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
2670035
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$571.72 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$1,319.36
|
| Rate for Payer: Aetna Medicare Advantage |
$1,319.36
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,121.46
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,121.46
|
| 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 |
$1,121.46
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$571.72
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$659.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
OP
|
$2,588.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
7411598
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$336.44 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$776.40
|
| Rate for Payer: Aetna Medicare Advantage |
$776.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$659.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$659.94
|
| 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 |
$659.94
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$336.44
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$388.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
IP
|
$4,397.88
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
2670035
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$659.68 |
| Max. Negotiated Rate |
$659.68 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$659.68
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
IP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
366849451
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$653.84 |
| Max. Negotiated Rate |
$653.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
IP
|
$2,588.00
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
7411598
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$388.20 |
| Max. Negotiated Rate |
$388.20 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$388.20
|
|
|
IR REPLMNT DUOD OR JEJUNST TUB
|
Facility
|
OP
|
$4,358.95
|
|
|
Service Code
|
HCPCS 49451
|
| Hospital Charge Code |
366849451
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$566.66 |
| Max. Negotiated Rate |
$3,687.00 |
| Rate for Payer: Aetna Commercial |
$1,307.68
|
| Rate for Payer: Aetna Medicare Advantage |
$1,307.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,111.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,111.53
|
| 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 |
$1,111.53
|
| Rate for Payer: Cigna Commercial |
$2,159.89
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$566.66
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$653.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
IP
|
$12,462.85
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
366836582
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,869.43 |
| Max. Negotiated Rate |
$1,869.43 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,869.43
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
OP
|
$12,618.93
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
7411467
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,640.46 |
| Max. Negotiated Rate |
$7,519.21 |
| Rate for Payer: Aetna Commercial |
$3,785.68
|
| Rate for Payer: Aetna Medicare Advantage |
$3,785.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,217.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,217.83
|
| 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 |
$3,217.83
|
| Rate for Payer: Cigna Commercial |
$7,519.21
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,640.46
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,892.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
OP
|
$15,468.50
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
321036582
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$7,519.21 |
| Rate for Payer: Aetna Commercial |
$4,640.55
|
| Rate for Payer: Aetna Medicare Advantage |
$4,640.55
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,944.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,944.47
|
| 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 |
$3,944.47
|
| Rate for Payer: Cigna Commercial |
$7,519.21
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,010.90
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,320.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
OP
|
$15,468.50
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
2670185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$7,519.21 |
| Rate for Payer: Aetna Commercial |
$4,640.55
|
| Rate for Payer: Aetna Medicare Advantage |
$4,640.55
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,944.47
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,944.47
|
| 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 |
$3,944.47
|
| Rate for Payer: Cigna Commercial |
$7,519.21
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,010.90
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,320.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
IP
|
$15,468.50
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
321036582
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,320.28 |
| Max. Negotiated Rate |
$2,320.28 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,320.28
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
IP
|
$15,468.50
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
2670185
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,320.28 |
| Max. Negotiated Rate |
$2,320.28 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,320.28
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
IP
|
$12,462.85
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
411036582
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,869.43 |
| Max. Negotiated Rate |
$1,869.43 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,869.43
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
IP
|
$12,618.93
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
7411467
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,892.84 |
| Max. Negotiated Rate |
$1,892.84 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,892.84
|
|
|
IR-REPLMT.COMPT.TUNNLED CVA-SV
|
Facility
|
OP
|
$12,462.85
|
|
|
Service Code
|
HCPCS 36582
|
| Hospital Charge Code |
366836582
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,620.17 |
| Max. Negotiated Rate |
$7,519.21 |
| Rate for Payer: Aetna Commercial |
$3,738.86
|
| Rate for Payer: Aetna Medicare Advantage |
$3,738.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,178.03
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,178.03
|
| 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 |
$3,178.03
|
| Rate for Payer: Cigna Commercial |
$7,519.21
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,620.17
|
| Rate for Payer: Oxford Commercial |
$6,055.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,869.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$6,873.00
|
|
