|
LIPOPROTEIN (A)
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 83695
|
| Hospital Charge Code |
39900104
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$38.95
|
| Rate for Payer: Aetna Medicare Advantage |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$51.95
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$51.95
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$14.32
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$13.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$51.95
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$14.32
|
| Rate for Payer: Clover Medicare Advantage |
$13.60
|
| Rate for Payer: EmblemHealth Commercial |
$42.96
|
| Rate for Payer: Humana Medicare Advantage |
$14.75
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$14.32
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$101.40
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$11.46
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$14.32
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.08
|
|
|
LIPOPROTEIN BLOOD QUANT LPN/LP
|
Facility
|
OP
|
$222.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
38477187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$93.00
|
| Rate for Payer: Aetna Medicare Advantage |
$110.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$34.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$34.07
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$124.02
|
| Rate for Payer: Cigna Commercial |
$111.00
|
| Rate for Payer: Cigna Medicare Advantage |
$34.19
|
| Rate for Payer: Clover Medicare Advantage |
$32.48
|
| Rate for Payer: EmblemHealth Commercial |
$102.57
|
| Rate for Payer: Humana Medicare Advantage |
$35.22
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$34.19
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$57.72
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$27.35
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$34.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.19
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$6.30
|
|
|
LIPOPROTEIN BLOOD QUANT LPN/LP
|
Facility
|
IP
|
$222.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
38477187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$33.30 |
| Max. Negotiated Rate |
$33.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$33.30
|
|
|
LIPOPROTEIN ELECTROPHORESIS
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 83700
|
| Hospital Charge Code |
38472458
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$36.30 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$36.30
|
|
|
LIPOPROTEIN ELECTROPHORESIS
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 83700
|
| Hospital Charge Code |
38472458
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Medicare Advantage |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$40.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$40.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$11.26
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$12.01
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$40.85
|
| Rate for Payer: Cigna Commercial |
$121.00
|
| Rate for Payer: Cigna Medicare Advantage |
$11.26
|
| Rate for Payer: Clover Medicare Advantage |
$10.70
|
| Rate for Payer: EmblemHealth Commercial |
$33.78
|
| Rate for Payer: Humana Medicare Advantage |
$11.60
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$11.26
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$62.92
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$36.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$11.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$11.26
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$6.87
|
|
|
LIPOPROTEIN FRACTIONATION I
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 82465
|
| Hospital Charge Code |
39990161A
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
LIPOPROTEIN FRACTIONATION I
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 82465
|
| Hospital Charge Code |
39990161A
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$11.83
|
| Rate for Payer: Aetna Medicare Advantage |
$14.09
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$15.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$15.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$4.35
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$4.95
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$15.78
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$4.35
|
| Rate for Payer: Clover Medicare Advantage |
$4.13
|
| Rate for Payer: EmblemHealth Commercial |
$13.05
|
| Rate for Payer: Humana Medicare Advantage |
$4.48
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$4.35
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$101.40
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$3.48
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.35
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.08
|
|
|
LIPOPROTEIN FRACTIONATION II
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 83701
|
| Hospital Charge Code |
39990161B
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
LIPOPROTEIN FRACTIONATION II
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 83701
|
| Hospital Charge Code |
39990161B
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$92.10
|
| Rate for Payer: Aetna Medicare Advantage |
$109.71
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$122.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$122.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$33.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$26.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$122.83
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$33.86
|
| Rate for Payer: Clover Medicare Advantage |
$32.17
|
| Rate for Payer: EmblemHealth Commercial |
$101.58
|
| Rate for Payer: Humana Medicare Advantage |
$34.88
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$33.86
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$101.40
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$27.09
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$33.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$33.86
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.08
|
|
|
LIPOPROTEIN FRACTIONATION III
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 84478
|
| Hospital Charge Code |
39990161C
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$15.61
|
| Rate for Payer: Aetna Medicare Advantage |
$18.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$20.82
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$5.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$13.70
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$20.82
|
| Rate for Payer: Cigna Commercial |
$195.00
|
| Rate for Payer: Cigna Medicare Advantage |
$5.74
|
| Rate for Payer: Clover Medicare Advantage |
$5.45
|
| Rate for Payer: EmblemHealth Commercial |
$17.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.91
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$5.74
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$101.40
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.59
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$5.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$5.74
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.08
|
|
|
LIPOPROTEIN FRACTIONATION III
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 84478
|
| Hospital Charge Code |
39990161C
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$58.50
|
|
|
LIPOPROTEIN FRACTIONATION NMR
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
401183704
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$7.50
|
|
|
LIPOPROTEIN FRACTIONATION NMR
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS 83704
|
| Hospital Charge Code |
401183704
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna Commercial |
$93.00
|
| Rate for Payer: Aetna Medicare Advantage |
$110.78
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$34.19
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$34.07
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$124.02
|
| Rate for Payer: Cigna Commercial |
$25.00
|
| Rate for Payer: Cigna Medicare Advantage |
$34.19
|
| Rate for Payer: Clover Medicare Advantage |
$32.48
|
| Rate for Payer: EmblemHealth Commercial |
$102.57
|
| Rate for Payer: Humana Medicare Advantage |
$35.22
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$34.19
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$13.00
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$7.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$27.35
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$34.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.19
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.42
|
|
|
LIQUID ADHESIVE
|
Facility
|
IP
|
$15.75
|
|
|
Service Code
|
NDC 496052348
|
| Hospital Charge Code |
60628531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.36
|
|
|
LIQUID ADHESIVE
|
Facility
|
OP
|
$15.75
|
|
|
Service Code
|
NDC 496052348
|
| Hospital Charge Code |
60628531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna Commercial |
$5.99
|
| Rate for Payer: Aetna Medicare Advantage |
$4.72
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$4.02
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4.09
|
| Rate for Payer: Oxford Commercial |
$3.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.15
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.50
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.45
|
|
|
LISDEXAMFETAMINE DIMESYLATE 20
|
Facility
|
OP
|
$38.19
|
|
|
Service Code
|
NDC 59417010210
|
| Hospital Charge Code |
6063943214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$14.51
|
| Rate for Payer: Aetna Medicare Advantage |
$11.46
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$9.74
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$9.93
|
| Rate for Payer: Oxford Commercial |
$7.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.64
|
| Rate for Payer: UnitedHealthcare Community & State |
$1.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.08
|
|
|
LISDEXAMFETAMINE DIMESYLATE 20
|
Facility
|
IP
|
$38.19
|
|
|
Service Code
|
NDC 59417010210
|
| Hospital Charge Code |
6063943214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.73
|
|
|
LISDEXAMFETAMINE DIMESYLATE 30
|
Facility
|
IP
|
$38.19
|
|
|
Service Code
|
NDC 59417010310
|
| Hospital Charge Code |
6063943215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$5.73 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.73
|
|
|
LISDEXAMFETAMINE DIMESYLATE 30
|
Facility
|
OP
|
$38.19
|
|
|
Service Code
|
NDC 59417010310
|
| Hospital Charge Code |
6063943215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$14.51
|
| Rate for Payer: Aetna Medicare Advantage |
$11.46
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$9.74
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$9.93
|
| Rate for Payer: Oxford Commercial |
$7.64
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$5.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.64
|
| Rate for Payer: UnitedHealthcare Community & State |
$1.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$1.08
|
|
|
LISFRANC PLATE LG LEFT
|
Facility
|
IP
|
$4,120.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
270702068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$997.04 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$824.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$997.04
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$618.00
|
|
|
LISFRANC PLATE LG LEFT
|
Facility
|
OP
|
$4,120.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
270702068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$117.01 |
| Max. Negotiated Rate |
$2,060.00 |
| Rate for Payer: Aetna Commercial |
$1,565.60
|
| Rate for Payer: Aetna Medicare Advantage |
$1,236.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,050.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,050.60
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$824.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,050.60
|
| Rate for Payer: Cigna Commercial |
$2,060.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$997.04
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$618.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$130.19
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$117.01
|
|
|
LISINOPRIL 10 MG TAB
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 51079098220
|
| Hospital Charge Code |
60627572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare Advantage |
$1.89
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.61
|
| Rate for Payer: Cigna Commercial |
$3.15
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.64
|
| Rate for Payer: Oxford Commercial |
$1.26
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.26
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.20
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.18
|
|
|
LISINOPRIL 10 MG TAB
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 51079098220
|
| Hospital Charge Code |
60627572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.95
|
|
|
LISINOPRIL 20 MG TAB
|
Facility
|
OP
|
$6.77
|
|
|
Service Code
|
NDC 51079098320
|
| Hospital Charge Code |
60627573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: Aetna Medicare Advantage |
$2.03
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.73
|
| Rate for Payer: Cigna Commercial |
$3.38
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.76
|
| Rate for Payer: Oxford Commercial |
$1.35
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.35
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.19
|
|
|
LISINOPRIL 20 MG TAB
|
Facility
|
IP
|
$6.77
|
|
|
Service Code
|
NDC 51079098320
|
| Hospital Charge Code |
60627573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1.02
|
|
