|
BALLOON EVERCROSS PTA 6X20X130
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644274S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x20x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644274
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x20x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644274
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x20x80
|
Facility
|
IP
|
$575.00
|
|
| Hospital Charge Code |
270671615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x20x80
|
Facility
|
OP
|
$575.00
|
|
| Hospital Charge Code |
270671615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x30mm
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644466N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x30mm
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644466N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x30mm
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x30mm
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644466
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270684979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270684979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x80
|
Facility
|
IP
|
$575.00
|
|
| Hospital Charge Code |
270671616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x40x80
|
Facility
|
OP
|
$575.00
|
|
| Hospital Charge Code |
270671616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$204.33
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x80
|
Facility
|
OP
|
$575.00
|
|
| Hospital Charge Code |
270671617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$172.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x80
|
Facility
|
IP
|
$575.00
|
|
| Hospital Charge Code |
270671617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
