|
SELENIUM
|
Facility
|
IP
|
$449.00
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
38472609
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$67.35 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$67.35
|
|
|
SELENIUM
|
Facility
|
IP
|
$175.50
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
39900130
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.32
|
|
|
SELENIUM
|
Facility
|
OP
|
$449.00
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
38472609
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$82.72
|
| Rate for Payer: Aetna Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$55.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$93.54
|
| Rate for Payer: Cigna Commercial |
$25.53
|
| Rate for Payer: Cigna Medicare Advantage |
$12.77
|
| Rate for Payer: Clover Medicare Advantage |
$24.25
|
| Rate for Payer: EmblemHealth Commercial |
$76.59
|
| Rate for Payer: Humana Medicare Advantage |
$26.30
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$58.37
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$67.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$25.53
|
| Rate for Payer: Wellcare Ambetter Commercial-Exchange |
$27.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.53
|
|
|
SELENIUM
|
Facility
|
OP
|
$175.50
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
39900130
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$82.72
|
| Rate for Payer: Aetna Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$55.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$93.54
|
| Rate for Payer: Cigna Commercial |
$25.53
|
| Rate for Payer: Cigna Medicare Advantage |
$12.77
|
| Rate for Payer: Clover Medicare Advantage |
$24.25
|
| Rate for Payer: EmblemHealth Commercial |
$76.59
|
| Rate for Payer: Humana Medicare Advantage |
$26.30
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.82
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$25.53
|
| Rate for Payer: Wellcare Ambetter Commercial-Exchange |
$27.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.53
|
|
|
SELENIUM 2.5% SHAMPOO
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
60628362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Medicare Advantage |
$21.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$18.36
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$18.36
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$18.36
|
| Rate for Payer: Cigna Commercial |
$36.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$9.36
|
| Rate for Payer: Oxford Commercial |
$36.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.00
|
|
|
SELENIUM 2.5% SHAMPOO
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
60628362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$10.80
|
|
|
SELENIUM 400 MCG/10ML INJ
|
Facility
|
IP
|
$22.45
|
|
| Hospital Charge Code |
60628928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$3.37
|
|
|
SELENIUM 400 MCG/10ML INJ
|
Facility
|
OP
|
$22.45
|
|
| Hospital Charge Code |
60628928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Aetna Commercial |
$6.74
|
| Rate for Payer: Aetna Medicare Advantage |
$6.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$5.72
|
| Rate for Payer: Cigna Commercial |
$11.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2.92
|
| Rate for Payer: Oxford Commercial |
$11.22
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$3.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.22
|
|
|
SELENIUM 40MCG SDV
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
60635520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.30
|
|
|
SELENIUM 40MCG SDV
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
60635520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.60
|
| Rate for Payer: Aetna Medicare Advantage |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$0.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$0.51
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$0.51
|
| Rate for Payer: Cigna Commercial |
$1.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$0.26
|
| Rate for Payer: Oxford Commercial |
$1.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.00
|
|
|
SELENIUM 50 MCG TAB
|
Facility
|
IP
|
$2.45
|
|
| Hospital Charge Code |
60628927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.37
|
|
|
SELENIUM 50 MCG TAB
|
Facility
|
OP
|
$2.45
|
|
| Hospital Charge Code |
60628927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$0.74
|
| Rate for Payer: Aetna Medicare Advantage |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$0.62
|
| Rate for Payer: Cigna Commercial |
$1.23
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$0.32
|
| Rate for Payer: Oxford Commercial |
$1.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.23
|
|
|
SELENIUM, SERUM/PLASMA
|
Facility
|
OP
|
$175.50
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
3038138
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$82.72
|
| Rate for Payer: Aetna Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$93.54
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$55.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$93.54
|
| Rate for Payer: Cigna Commercial |
$25.53
|
| Rate for Payer: Cigna Medicare Advantage |
$12.77
|
| Rate for Payer: Clover Medicare Advantage |
$24.25
|
| Rate for Payer: EmblemHealth Commercial |
$76.59
|
| Rate for Payer: Humana Medicare Advantage |
$26.30
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$22.82
|
| Rate for Payer: Oxford Commercial |
$101.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$25.53
|
| Rate for Payer: Wellcare Ambetter Commercial-Exchange |
$27.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.53
|
|
|
SELENIUM, SERUM/PLASMA
|
Facility
|
IP
|
$175.50
|
|
|
Service Code
|
HCPCS 84255
|
| Hospital Charge Code |
3038138
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$26.32
|
|
|
SELENIUM SULF 2.5% 120ML
|
Facility
|
IP
|
$19.85
|
|
| Hospital Charge Code |
6004865
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.98
|
|
|
SELENIUM SULF 2.5% 120ML
|
Facility
|
OP
|
$19.85
|
|
| Hospital Charge Code |
6004865
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$9.93 |
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna Medicare Advantage |
$5.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$5.06
|
| Rate for Payer: Cigna Commercial |
$9.93
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2.58
|
| Rate for Payer: Oxford Commercial |
$9.93
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.93
|
|
|
selenium sulfide topical 2.5%
|
Facility
|
OP
|
$132.66
|
|
|
Service Code
|
NDC 45802004064
|
| Hospital Charge Code |
6063943318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$66.33 |
| Rate for Payer: Aetna Commercial |
$39.80
|
| Rate for Payer: Aetna Medicare Advantage |
$39.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$33.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$33.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$33.83
|
| Rate for Payer: Cigna Commercial |
$66.33
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$17.25
|
| Rate for Payer: Oxford Commercial |
$66.33
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.33
|
|
|
selenium sulfide topical 2.5%
|
Facility
|
IP
|
$132.66
|
|
|
Service Code
|
NDC 45802004064
|
| Hospital Charge Code |
6063943318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.90 |
| Max. Negotiated Rate |
$19.90 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.90
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
IP
|
$800.80
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
83246295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$120.12 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
IP
|
$800.80
|
|
| Hospital Charge Code |
24746295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$120.12 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
OP
|
$800.80
|
|
| Hospital Charge Code |
24746295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$104.10 |
| Max. Negotiated Rate |
$400.40 |
| Rate for Payer: Aetna Commercial |
$240.24
|
| Rate for Payer: Aetna Medicare Advantage |
$240.24
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$204.20
|
| Rate for Payer: Cigna Commercial |
$400.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$104.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
OP
|
$800.80
|
|
|
Service Code
|
HCPCS 90853
|
| Hospital Charge Code |
83246295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$27.48 |
| Max. Negotiated Rate |
$241.93 |
| Rate for Payer: Aetna Commercial |
$240.24
|
| Rate for Payer: Aetna Medicare Advantage |
$240.24
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$45.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$204.20
|
| Rate for Payer: Cigna Commercial |
$241.93
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$104.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
| Rate for Payer: Wellcare New Jersey Medicaid/Family Care |
$27.48
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
IP
|
$800.80
|
|
| Hospital Charge Code |
24846295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$120.12 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
|
|
SELF AWARENESS GROUP PSYCHOTPY
|
Facility
|
OP
|
$800.80
|
|
| Hospital Charge Code |
24846295
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$104.10 |
| Max. Negotiated Rate |
$400.40 |
| Rate for Payer: Aetna Commercial |
$240.24
|
| Rate for Payer: Aetna Medicare Advantage |
$240.24
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$204.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$204.20
|
| Rate for Payer: Cigna Commercial |
$400.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$104.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$120.12
|
|
|
SELF BLOOD GLUC MONITOR EST PT
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS 98960
|
| Hospital Charge Code |
9200022
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$405.00 |
| Max. Negotiated Rate |
$405.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$405.00
|
|
