|
Pacific Plus 2x60x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683490N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 2x60x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x40x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683476N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x40x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x40x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x40x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683476N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x60x180
|
Facility
|
IP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$253.47 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3.5x60x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683477N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x60x180
|
Facility
|
OP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$523.70 |
| Rate for Payer: Aetna Commercial |
$314.22
|
| Rate for Payer: Aetna Medicare Advantage |
$314.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$267.09
|
| Rate for Payer: Cigna Commercial |
$523.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3.5x60x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683477N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x80x180
|
Facility
|
IP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$253.47 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3.5x80x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x80x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3.5x80x180
|
Facility
|
OP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$523.70 |
| Rate for Payer: Aetna Commercial |
$314.22
|
| Rate for Payer: Aetna Medicare Advantage |
$314.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$267.09
|
| Rate for Payer: Cigna Commercial |
$523.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
PACIFIC PLUS 3.5X80X180
|
Facility
|
OP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$523.70 |
| Rate for Payer: Aetna Commercial |
$314.22
|
| Rate for Payer: Aetna Medicare Advantage |
$314.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$267.09
|
| Rate for Payer: Cigna Commercial |
$523.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
PACIFIC PLUS 3.5X80X180
|
Facility
|
IP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683478S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$253.47 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3x120x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683474N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x120x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683474N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x120x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683474
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x120x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683474
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x150x180
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683475N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$275.88 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x150x180
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683475N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Medicare Advantage |
$342.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$228.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$290.70
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$275.88
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$171.00
|
|
|
Pacific Plus 3x150x180
|
Facility
|
IP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$253.47 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3x150x180
|
Facility
|
OP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$523.70 |
| Rate for Payer: Aetna Commercial |
$314.22
|
| Rate for Payer: Aetna Medicare Advantage |
$314.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$267.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$267.09
|
| Rate for Payer: Cigna Commercial |
$523.70
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|
|
Pacific Plus 3x40x180
|
Facility
|
IP
|
$1,047.40
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270683471
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$157.11 |
| Max. Negotiated Rate |
$253.47 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$209.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$253.47
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$157.11
|
|