|
STENT VERIFLEX 32mm 4.50
|
Facility
|
OP
|
$6,250.00
|
|
| Hospital Charge Code |
270CH0082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,125.00 |
| Rate for Payer: Aetna Commercial |
$1,875.00
|
| Rate for Payer: Aetna Medicare Advantage |
$1,875.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,250.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,593.75
|
| Rate for Payer: Cigna Commercial |
$3,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,512.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$937.50
|
|
|
STENT VERIFLEX 8mm 2.75
|
Facility
|
IP
|
$6,250.00
|
|
| Hospital Charge Code |
270638260
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$1,512.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,250.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,512.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$937.50
|
|
|
STENT VERIFLEX 8mm 2.75
|
Facility
|
OP
|
$6,250.00
|
|
| Hospital Charge Code |
270638260
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,125.00 |
| Rate for Payer: Aetna Commercial |
$1,875.00
|
| Rate for Payer: Aetna Medicare Advantage |
$1,875.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,250.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,593.75
|
| Rate for Payer: Cigna Commercial |
$3,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,512.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$937.50
|
|
|
STENT VERIFLX 4 0X32 389343240
|
Facility
|
OP
|
$6,250.00
|
|
| Hospital Charge Code |
270661689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,125.00 |
| Rate for Payer: Aetna Commercial |
$1,875.00
|
| Rate for Payer: Aetna Medicare Advantage |
$1,875.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,593.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,250.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,593.75
|
| Rate for Payer: Cigna Commercial |
$3,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,512.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$937.50
|
|
|
STENT VERIFLX 4 0X32 389343240
|
Facility
|
IP
|
$6,250.00
|
|
| Hospital Charge Code |
270661689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$1,512.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,250.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,512.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$937.50
|
|
|
STENT VI 8F 7X10 120 VBH071002
|
Facility
|
OP
|
$15,250.00
|
|
| Hospital Charge Code |
270640342C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,287.50 |
| Max. Negotiated Rate |
$7,625.00 |
| Rate for Payer: Aetna Commercial |
$4,575.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,575.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,888.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,888.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,050.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,888.75
|
| Rate for Payer: Cigna Commercial |
$7,625.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,690.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,287.50
|
|
|
STENT VI 8F 7X10 120 VBH071002
|
Facility
|
IP
|
$15,250.00
|
|
| Hospital Charge Code |
270640342C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,287.50 |
| Max. Negotiated Rate |
$3,690.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$3,050.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,690.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,287.50
|
|
|
STENT VIABAH 13x10x75 VB131001
|
Facility
|
OP
|
$12,152.00
|
|
| Hospital Charge Code |
270635161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$6,076.00 |
| Rate for Payer: Aetna Commercial |
$3,645.60
|
| Rate for Payer: Aetna Medicare Advantage |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,098.76
|
| Rate for Payer: Cigna Commercial |
$6,076.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 13x10x75 VB131001
|
Facility
|
OP
|
$12,152.00
|
|
| Hospital Charge Code |
270635161V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$6,076.00 |
| Rate for Payer: Aetna Commercial |
$3,645.60
|
| Rate for Payer: Aetna Medicare Advantage |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,098.76
|
| Rate for Payer: Cigna Commercial |
$6,076.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 13x10x75 VB131001
|
Facility
|
IP
|
$12,152.00
|
|
| Hospital Charge Code |
270635161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$2,940.78 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 13x10x75 VB131001
|
Facility
|
IP
|
$12,152.00
|
|
| Hospital Charge Code |
270635161V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$2,940.78 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 13X10X75 VB131001
|
Facility
|
IP
|
$13,400.00
|
|
| Hospital Charge Code |
270636760V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.00 |
| Max. Negotiated Rate |
$3,242.80 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,680.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,242.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,010.00
|
|
|
STENT VIABAH 13X10X75 VB131001
|
Facility
|
OP
|
$13,400.00
|
|
| Hospital Charge Code |
270636760V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,010.00 |
| Max. Negotiated Rate |
$6,700.00 |
| Rate for Payer: Aetna Commercial |
$4,020.00
|
| Rate for Payer: Aetna Medicare Advantage |
$4,020.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,417.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,417.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,680.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,417.00
|
| Rate for Payer: Cigna Commercial |
$6,700.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,242.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2,010.00
|
|
|
STENT VIABAH 7x10x75 VBA071001
|
Facility
|
IP
|
$12,152.00
|
|
| Hospital Charge Code |
270633716V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$2,940.78 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 7x10x75 VBA071001
|
Facility
|
OP
|
$12,152.00
|
|
| Hospital Charge Code |
270633716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$6,076.00 |
| Rate for Payer: Aetna Commercial |
$3,645.60
|
| Rate for Payer: Aetna Medicare Advantage |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,098.76
|
| Rate for Payer: Cigna Commercial |
$6,076.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 7x10x75 VBA071001
|
Facility
|
OP
|
$12,152.00
|
|
| Hospital Charge Code |
270633716V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$6,076.00 |
| Rate for Payer: Aetna Commercial |
$3,645.60
|
| Rate for Payer: Aetna Medicare Advantage |
$3,645.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,098.76
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,098.76
|
| Rate for Payer: Cigna Commercial |
$6,076.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 7x10x75 VBA071001
|
Facility
|
IP
|
$12,152.00
|
|
| Hospital Charge Code |
270633716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.80 |
| Max. Negotiated Rate |
$2,940.78 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,430.40
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,940.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,822.80
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
IP
|
$10,168.00
|
|
| Hospital Charge Code |
270634384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,525.20 |
| Max. Negotiated Rate |
$2,460.66 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,033.60
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,460.66
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,525.20
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
OP
|
$10,168.00
|
|
| Hospital Charge Code |
270634384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,525.20 |
| Max. Negotiated Rate |
$5,084.00 |
| Rate for Payer: Aetna Commercial |
$3,050.40
|
| Rate for Payer: Aetna Medicare Advantage |
$3,050.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,592.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,592.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,033.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,592.84
|
| Rate for Payer: Cigna Commercial |
$5,084.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,460.66
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,525.20
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
IP
|
$10,250.00
|
|
| Hospital Charge Code |
270634384V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$2,480.50 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,050.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,480.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,537.50
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
OP
|
$12,710.00
|
|
| Hospital Charge Code |
70634384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.50 |
| Max. Negotiated Rate |
$6,355.00 |
| Rate for Payer: Aetna Commercial |
$3,813.00
|
| Rate for Payer: Aetna Medicare Advantage |
$3,813.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$3,241.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$3,241.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,542.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$3,241.05
|
| Rate for Payer: Cigna Commercial |
$6,355.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,075.82
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,906.50
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
IP
|
$12,710.00
|
|
| Hospital Charge Code |
70634384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,906.50 |
| Max. Negotiated Rate |
$3,075.82 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,542.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,075.82
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,906.50
|
|
|
STENT VIABAH 7x5 100 VBA070502
|
Facility
|
OP
|
$10,250.00
|
|
| Hospital Charge Code |
270634384V
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,537.50 |
| Max. Negotiated Rate |
$5,125.00 |
| Rate for Payer: Aetna Commercial |
$3,075.00
|
| Rate for Payer: Aetna Medicare Advantage |
$3,075.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,613.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,613.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,050.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,613.75
|
| Rate for Payer: Cigna Commercial |
$5,125.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,480.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,537.50
|
|
|
STENT VIABAHAN 8X10X120MM
|
Facility
|
OP
|
$20,550.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
270695023S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,082.50 |
| Max. Negotiated Rate |
$10,275.00 |
| Rate for Payer: Aetna Commercial |
$6,165.00
|
| Rate for Payer: Aetna Medicare Advantage |
$6,165.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$5,240.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$5,240.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$4,110.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$5,240.25
|
| Rate for Payer: Cigna Commercial |
$10,275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,973.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$3,082.50
|
|
|
STENT VIABAHAN 8X10X120MM
|
Facility
|
IP
|
$20,550.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
270695023S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,082.50 |
| Max. Negotiated Rate |
$4,973.10 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$4,110.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4,973.10
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$3,082.50
|
|
