|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
2692146
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
366899151
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
366899151
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
2692146
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
5792285
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
2500264
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
5792285
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
2500264
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
7412069
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
321099151
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
IP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
7412069
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
|
|
MOD SED SAME MD <5YO 1ST 15MIN
|
Facility
|
OP
|
$127.95
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
5100848
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$63.98 |
| Rate for Payer: Aetna Commercial |
$38.38
|
| Rate for Payer: Aetna Medicare Advantage |
$38.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$32.63
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$32.63
|
| Rate for Payer: Cigna Commercial |
$22.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$16.63
|
| Rate for Payer: Oxford Commercial |
$63.98
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.98
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
5792286
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
366899152
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
5792286
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
321099152
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
2692141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
5100849
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
7412070
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
2500265
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
321099152
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
5100849
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
7412070
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
IP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
2692141
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
|
|
MOD SED SAME MD >5YO 1ST 15MIN
|
Facility
|
OP
|
$67.30
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
2500265
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna Commercial |
$20.19
|
| Rate for Payer: Aetna Medicare Advantage |
$20.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$17.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$17.16
|
| Rate for Payer: Cigna Commercial |
$11.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$8.75
|
| Rate for Payer: Oxford Commercial |
$33.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.65
|
|
