|
THROMBECTOMY/LYSIS DIALYS CIRC
|
Facility
|
OP
|
$27,397.00
|
|
|
Service Code
|
HCPCS 36904
|
| Hospital Charge Code |
2692148
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$13,553.85 |
| Rate for Payer: Aetna Commercial |
$8,219.10
|
| Rate for Payer: Aetna Medicare Advantage |
$8,219.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$6,986.23
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$6,986.23
|
| 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 |
$6,986.23
|
| Rate for Payer: Cigna Commercial |
$13,553.85
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,561.61
|
| Rate for Payer: Oxford Commercial |
$8,679.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$4,109.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,851.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
OP
|
$2,240.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$1,120.00 |
| Rate for Payer: Aetna Commercial |
$672.00
|
| Rate for Payer: Aetna Medicare Advantage |
$672.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$571.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$571.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$448.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,120.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$542.08
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$336.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
IP
|
$2,240.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$542.08 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$448.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$542.08
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$336.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Commercial |
$3,000.00
|
| Rate for Payer: Aetna Medicare Advantage |
$3,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,550.00
|
| Rate for Payer: Cigna Commercial |
$5,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
IP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$2,420.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
OP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Commercial |
$3,000.00
|
| Rate for Payer: Aetna Medicare Advantage |
$3,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,550.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,550.00
|
| Rate for Payer: Cigna Commercial |
$5,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
THROMBECTOMY SET 4FR SOLENT
|
Facility
|
IP
|
$10,000.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270650590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$2,420.00 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$2,000.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,420.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,500.00
|
|
|
THROMBECTOMY SET AVX ULTRA
|
Facility
|
IP
|
$3,625.00
|
|
| Hospital Charge Code |
270657876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$543.75 |
| Max. Negotiated Rate |
$877.25 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$725.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$877.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$543.75
|
|
|
THROMBECTOMY SET AVX ULTRA
|
Facility
|
OP
|
$3,625.00
|
|
| Hospital Charge Code |
270657876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$543.75 |
| Max. Negotiated Rate |
$1,812.50 |
| Rate for Payer: Aetna Commercial |
$1,087.50
|
| Rate for Payer: Aetna Medicare Advantage |
$1,087.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$924.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$924.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$725.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$924.38
|
| Rate for Payer: Cigna Commercial |
$1,812.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$877.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$543.75
|
|
|
THROMBECTOMY SET AVX ULTRA
|
Facility
|
OP
|
$3,625.00
|
|
| Hospital Charge Code |
2709006400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$471.25 |
| Max. Negotiated Rate |
$1,812.50 |
| Rate for Payer: Aetna Commercial |
$1,087.50
|
| Rate for Payer: Aetna Medicare Advantage |
$1,087.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$924.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$924.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$924.38
|
| Rate for Payer: Cigna Commercial |
$1,812.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$471.25
|
| Rate for Payer: Oxford Commercial |
$1,812.50
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$543.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,812.50
|
|
|
THROMBECTOMY SET AVX ULTRA
|
Facility
|
IP
|
$3,625.00
|
|
| Hospital Charge Code |
2709006400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$543.75 |
| Max. Negotiated Rate |
$543.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$543.75
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
IP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,267.50 |
| Max. Negotiated Rate |
$2,044.90 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,690.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,044.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,267.50
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
OP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,267.50 |
| Max. Negotiated Rate |
$4,225.00 |
| Rate for Payer: Aetna Commercial |
$2,535.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,535.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,154.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,154.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,690.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,154.75
|
| Rate for Payer: Cigna Commercial |
$4,225.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,044.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,267.50
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
IP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,267.50 |
| Max. Negotiated Rate |
$2,044.90 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,690.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,044.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,267.50
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
OP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,267.50 |
| Max. Negotiated Rate |
$4,225.00 |
| Rate for Payer: Aetna Commercial |
$2,535.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,535.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,154.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,154.75
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,690.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,154.75
|
| Rate for Payer: Cigna Commercial |
$4,225.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,044.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,267.50
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
IP
|
$9,600.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,440.00 |
| Max. Negotiated Rate |
$2,323.20 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,920.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,323.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,440.00
|
|
|
THROMBECTOMY SET SOLENT OMNI U
|
Facility
|
OP
|
$9,600.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270648590N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,440.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$2,880.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,880.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,920.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$4,800.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,323.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,440.00
|
|
|
THROMBECTOMY SET SOLENT PROXI
|
Facility
|
OP
|
$9,100.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270657885
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$4,550.00 |
| Rate for Payer: Aetna Commercial |
$2,730.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,730.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,320.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,320.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,820.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,320.50
|
| Rate for Payer: Cigna Commercial |
$4,550.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,202.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,365.00
|
|
|
THROMBECTOMY SET SOLENT PROXI
|
Facility
|
IP
|
$9,100.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270657885
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$2,202.20 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,820.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,202.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,365.00
|
|
|
THROMBECTOMY SET SO OMNI ULTRA
|
Facility
|
OP
|
$9,600.00
|
|
| Hospital Charge Code |
2709007191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,248.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$2,880.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,880.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,448.00
|
| Rate for Payer: Cigna Commercial |
$4,800.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,248.00
|
| Rate for Payer: Oxford Commercial |
$4,800.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,440.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,800.00
|
|
|
THROMBECTOMY SET SO OMNI ULTRA
|
Facility
|
IP
|
$9,600.00
|
|
| Hospital Charge Code |
2709007191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,440.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,440.00
|
|
|
THROMBECTOMY SET SO PROX ULTRA
|
Facility
|
IP
|
$9,100.00
|
|
| Hospital Charge Code |
2709007190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$1,365.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,365.00
|
|
|
THROMBECTOMY SET SO PROX ULTRA
|
Facility
|
OP
|
$9,100.00
|
|
| Hospital Charge Code |
2709007190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,183.00 |
| Max. Negotiated Rate |
$4,550.00 |
| Rate for Payer: Aetna Commercial |
$2,730.00
|
| Rate for Payer: Aetna Medicare Advantage |
$2,730.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,320.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,320.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,320.50
|
| Rate for Payer: Cigna Commercial |
$4,550.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,183.00
|
| Rate for Payer: Oxford Commercial |
$4,550.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,365.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,550.00
|
|
|
THROMBECTOMY SET SPIROFLEX
|
Facility
|
OP
|
$2,070.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270645707N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$310.50 |
| Max. Negotiated Rate |
$1,035.00 |
| Rate for Payer: Aetna Commercial |
$621.00
|
| Rate for Payer: Aetna Medicare Advantage |
$621.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$527.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$527.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$414.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$527.85
|
| Rate for Payer: Cigna Commercial |
$1,035.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$500.94
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.50
|
|
|
THROMBECTOMY SET SPIROFLEX
|
Facility
|
IP
|
$2,070.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
270645707N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$310.50 |
| Max. Negotiated Rate |
$500.94 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$414.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$500.94
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.50
|
|
