|
PEDICLE FLAP,TRUNK
|
Facility
|
OP
|
$16,902.88
|
|
|
Service Code
|
HCPCS 15570
|
| Hospital Charge Code |
1600059816
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$5,070.86 |
| Rate for Payer: Aetna Commercial |
$5,070.86
|
| Rate for Payer: Aetna Medicare Advantage |
$5,070.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4,310.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4,310.23
|
| 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 |
$4,310.23
|
| Rate for Payer: Cigna Commercial |
$4,913.48
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,197.37
|
| Rate for Payer: Oxford Commercial |
$3,248.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,535.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,687.00
|
|
|
PEDICLE FLAP,TRUNK
|
Facility
|
IP
|
$16,902.88
|
|
|
Service Code
|
HCPCS 15570
|
| Hospital Charge Code |
16000598
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,535.43 |
| Max. Negotiated Rate |
$2,535.43 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,535.43
|
|
|
PEDICLE FLAP,TRUNK
|
Facility
|
IP
|
$16,902.88
|
|
|
Service Code
|
HCPCS 15570
|
| Hospital Charge Code |
1600059816
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,535.43 |
| Max. Negotiated Rate |
$2,535.43 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,535.43
|
|
|
PED NB CARE
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 99431
|
| Hospital Charge Code |
87502375
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
|
|
PED NB CARE
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 99431
|
| Hospital Charge Code |
87502375
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Medicare Advantage |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$38.25
|
| Rate for Payer: Cigna Commercial |
$75.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$19.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
|
|
PED PREV E&M NP 12-17 YRS OLD
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
87502805
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP 12-17 YRS OLD
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
87502805
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP 12-17 YRS. OLD
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
83652475
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.65
|
|
|
PED PREV E&M NP 12-17 YRS. OLD
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
83652475
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$35.50 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Aetna Medicare Advantage |
$21.30
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$18.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$18.11
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$18.11
|
| Rate for Payer: Cigna Commercial |
$35.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$9.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.65
|
|
|
PED PREV E&M NP 1-4 YRS OLD
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
83652471
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$29.50 |
| Rate for Payer: Aetna Commercial |
$17.70
|
| Rate for Payer: Aetna Medicare Advantage |
$17.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15.04
|
| Rate for Payer: Cigna Commercial |
$29.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$7.67
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV E&M NP 1-4 YRS OLD
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
83652471
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV E&M NP 1-4 YRS OLD
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
87502795
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP 1-4 YRS OLD
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
87502795
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP < 1 YEAR
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
87502790
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
|
|
PED PREV E&M NP < 1 YEAR
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
87502790
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV. E&M NP < 1 YEAR OLD
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
83652469
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV. E&M NP < 1 YEAR OLD
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
83652469
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$29.50 |
| Rate for Payer: Aetna Commercial |
$17.70
|
| Rate for Payer: Aetna Medicare Advantage |
$17.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15.04
|
| Rate for Payer: Cigna Commercial |
$29.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$7.67
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV E&M NP 5-11 YRS OLD
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
87502800
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP 5-11 YRS OLD
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
83652473
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$29.50 |
| Rate for Payer: Aetna Commercial |
$17.70
|
| Rate for Payer: Aetna Medicare Advantage |
$17.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15.04
|
| Rate for Payer: Cigna Commercial |
$29.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$7.67
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV E&M NP 5-11 YRS OLD
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
87502800
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV E&M NP 5-11 YRS OLD
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
83652473
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$8.85
|
|
|
PED PREV EST PT 12 TO 17 YRS
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
83652489
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV EST PT 12 TO 17 YRS
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
83652489
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV EST PT 5 TO 11 YRS
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
83652487
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna Commercial |
$52.50
|
| Rate for Payer: Aetna Medicare Advantage |
$52.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$44.62
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
|
PED PREV EST PT 5 TO 11 YRS
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
83652487
|
|
Hospital Revenue Code
|
515
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.25
|
|
