|
NMDA RECEPTOR AB TEST
|
Facility
|
OP
|
$2,650.00
|
|
|
Service Code
|
HCPCS 86255
|
| Hospital Charge Code |
39990240
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$1,325.00 |
| Rate for Payer: Aetna Commercial |
$32.78
|
| Rate for Payer: Aetna Medicare Advantage |
$39.04
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$43.71
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$43.71
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$12.87
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$43.71
|
| Rate for Payer: Cigna Commercial |
$1,325.00
|
| Rate for Payer: Cigna Medicare Advantage |
$12.05
|
| Rate for Payer: Clover Medicare Advantage |
$11.45
|
| Rate for Payer: EmblemHealth Commercial |
$36.15
|
| Rate for Payer: Humana Medicare Advantage |
$12.41
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$12.05
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$689.00
|
| Rate for Payer: Oxford Commercial |
$156.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$397.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.64
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$12.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.05
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$75.26
|
|
|
NM GALLIUM 67 PER mCi
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
4500823
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$62.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$62.25
|
|
|
NM GALLIUM 67 PER mCi
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
4500823
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$207.50 |
| Rate for Payer: Aetna Commercial |
$157.70
|
| Rate for Payer: Aetna Medicare Advantage |
$124.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$127.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$105.83
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$107.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$62.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$13.11
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$11.79
|
|
|
NM GALLUIM SPECT
|
Facility
|
OP
|
$2,820.00
|
|
|
Service Code
|
HCPCS 78807
|
| Hospital Charge Code |
4500518
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$80.09 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,071.60
|
| Rate for Payer: Aetna Medicare Advantage |
$846.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$719.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$719.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$719.10
|
| Rate for Payer: Cigna Commercial |
$1,410.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$733.20
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$423.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$89.11
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$80.09
|
|
|
NM GALLUIM SPECT
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS 78807
|
| Hospital Charge Code |
4500518
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$423.00 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$423.00
|
|
|
NM GASTRIC EMPTYING STUDY
|
Facility
|
IP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
4500732
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,800.00 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
|
|
NM GASTRIC EMPTYING STUDY
|
Facility
|
OP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78264
|
| Hospital Charge Code |
4500732
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,291.84
|
| Rate for Payer: Aetna Medicare Advantage |
$1,538.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$474.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$56.10
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,722.84
|
| Rate for Payer: Cigna Commercial |
$952.02
|
| Rate for Payer: Cigna Medicare Advantage |
$332.46
|
| Rate for Payer: Clover Medicare Advantage |
$451.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,424.82
|
| Rate for Payer: Humana Medicare Advantage |
$489.19
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$474.94
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,120.00
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$379.20
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$340.80
|
|
|
NM GASTROESOPH REFLUX
|
Facility
|
OP
|
$1,421.00
|
|
|
Service Code
|
HCPCS 78262
|
| Hospital Charge Code |
4500419
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$40.36 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,291.84
|
| Rate for Payer: Aetna Medicare Advantage |
$1,538.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$474.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$52.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,722.84
|
| Rate for Payer: Cigna Commercial |
$952.02
|
| Rate for Payer: Cigna Medicare Advantage |
$332.46
|
| Rate for Payer: Clover Medicare Advantage |
$451.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,424.82
|
| Rate for Payer: Humana Medicare Advantage |
$489.19
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$474.94
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$369.46
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$213.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$44.90
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$40.36
|
|
|
NM GASTROESOPH REFLUX
|
Facility
|
IP
|
$1,421.00
|
|
|
Service Code
|
HCPCS 78262
|
| Hospital Charge Code |
4500419
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$213.15 |
| Max. Negotiated Rate |
$213.15 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$213.15
|
|
|
NM GASTROINTES BLOOD LOSS
|
Facility
|
IP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78278
|
| Hospital Charge Code |
4500328
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,800.00 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
|
|
NM GASTROINTES BLOOD LOSS
|
Facility
|
OP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78278
|
| Hospital Charge Code |
4500328
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$80.85 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,291.84
|
| Rate for Payer: Aetna Medicare Advantage |
$1,538.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$474.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$80.85
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,722.84
|
| Rate for Payer: Cigna Commercial |
$952.02
|
| Rate for Payer: Cigna Medicare Advantage |
$332.46
|
| Rate for Payer: Clover Medicare Advantage |
$451.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,424.82
|
| Rate for Payer: Humana Medicare Advantage |
$489.19
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$474.94
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,120.00
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$379.20
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$340.80
|
|
|
NM HEPATOBIL IMAG W GALLBALLAD
|
Facility
|
OP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78226
|
| Hospital Charge Code |
4500910
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$242.22 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,291.84
|
| Rate for Payer: Aetna Medicare Advantage |
$1,538.81
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,722.84
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$474.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$242.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,722.84
|
| Rate for Payer: Cigna Commercial |
$952.02
|
| Rate for Payer: Cigna Medicare Advantage |
$332.46
|
| Rate for Payer: Clover Medicare Advantage |
$451.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,424.82
|
| Rate for Payer: Humana Medicare Advantage |
$489.19
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$474.94
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,120.00
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$379.20
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$474.94
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$340.80
|
|
|
NM HEPATOBIL IMAG W GALLBALLAD
|
Facility
|
IP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78226
|
| Hospital Charge Code |
4500910
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,800.00 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
|
|
NM HEPATO W GALL W PHAMA INTER
|
Facility
|
OP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78227
|
| Hospital Charge Code |
4500336
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$331.88 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$1,754.56
|
| Rate for Payer: Aetna Medicare Advantage |
$2,089.99
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2,339.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2,339.96
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$645.06
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$331.88
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2,339.96
|
| Rate for Payer: Cigna Commercial |
$1,293.03
|
| Rate for Payer: Cigna Medicare Advantage |
$451.54
|
| Rate for Payer: Clover Medicare Advantage |
$612.81
|
| Rate for Payer: EmblemHealth Commercial |
$1,935.18
|
| Rate for Payer: Humana Medicare Advantage |
$664.41
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$645.06
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$3,120.00
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$379.20
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$645.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$645.06
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$340.80
|
|
|
NM HEPATO W GALL W PHAMA INTER
|
Facility
|
IP
|
$12,000.00
|
|
|
Service Code
|
HCPCS 78227
|
| Hospital Charge Code |
4500336
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,800.00 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,800.00
|
|
|
NM I-123 EA 100 UCI UP TO 999U
|
Facility
|
OP
|
$315.00
|
|
| Hospital Charge Code |
4500807
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna Commercial |
$119.70
|
| Rate for Payer: Aetna Medicare Advantage |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$80.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$80.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$80.33
|
| Rate for Payer: Cigna Commercial |
$157.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$81.90
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$47.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$9.95
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$8.95
|
|
|
NM I-123 EA 100 UCI UP TO 999U
|
Facility
|
IP
|
$315.00
|
|
| Hospital Charge Code |
4500807
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$47.25 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$47.25
|
|
|
NM I 131 THERAPY INITIAL
|
Facility
|
OP
|
$1,363.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
4500013
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$4,820.00 |
| Rate for Payer: Aetna Commercial |
$754.01
|
| Rate for Payer: Aetna Medicare Advantage |
$898.16
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1,005.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1,005.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$277.21
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$177.26
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1,005.58
|
| Rate for Payer: Cigna Commercial |
$555.67
|
| Rate for Payer: Cigna Medicare Advantage |
$194.05
|
| Rate for Payer: Clover Medicare Advantage |
$263.35
|
| Rate for Payer: EmblemHealth Commercial |
$831.63
|
| Rate for Payer: Humana Medicare Advantage |
$285.53
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$277.21
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$354.38
|
| Rate for Payer: Oxford Commercial |
$4,820.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$204.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,748.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.07
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$277.21
|
| Rate for Payer: Wellcare Medicare Advantage |
$277.21
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$38.71
|
|
|
NM I 131 THERAPY INITIAL
|
Facility
|
IP
|
$1,363.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
4500013
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$204.45 |
| Max. Negotiated Rate |
$204.45 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$204.45
|
|
|
NM IN-111 PENTETREOTIDE DOSE U
|
Facility
|
OP
|
$11,534.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
4501021
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$327.57 |
| Max. Negotiated Rate |
$7,258.41 |
| Rate for Payer: Aetna Commercial |
$5,442.56
|
| Rate for Payer: Aetna Medicare Advantage |
$6,483.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$7,258.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$7,258.41
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$2,000.94
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$1,263.64
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$7,258.41
|
| Rate for Payer: Cigna Medicare Advantage |
$1,400.66
|
| Rate for Payer: Clover Medicare Advantage |
$1,900.89
|
| Rate for Payer: EmblemHealth Commercial |
$6,002.82
|
| Rate for Payer: Humana Medicare Advantage |
$2,060.97
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$2,000.94
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2,998.84
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,730.10
|
| Rate for Payer: UnitedHealthcare Community & State |
$364.47
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$2,000.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,000.94
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$327.57
|
|
|
NM IN-111 PENTETREOTIDE DOSE U
|
Facility
|
IP
|
$11,534.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
4501021
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,730.10 |
| Max. Negotiated Rate |
$1,730.10 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$1,730.10
|
|
|
NM INDIUM DTPA/0.5 MCI
|
Facility
|
IP
|
$3,503.00
|
|
| Hospital Charge Code |
4508055
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$525.45 |
| Max. Negotiated Rate |
$525.45 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$525.45
|
|
|
NM INDIUM DTPA/0.5 MCI
|
Facility
|
OP
|
$3,503.00
|
|
| Hospital Charge Code |
4508055
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$99.49 |
| Max. Negotiated Rate |
$1,751.50 |
| Rate for Payer: Aetna Commercial |
$1,331.14
|
| Rate for Payer: Aetna Medicare Advantage |
$1,050.90
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$893.26
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$893.26
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$893.26
|
| Rate for Payer: Cigna Commercial |
$1,751.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$910.78
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$525.45
|
| Rate for Payer: UnitedHealthcare Community & State |
$110.69
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$99.49
|
|
|
NM INDIUM III OXYQUIN / 5mCi
|
Facility
|
IP
|
$2,070.00
|
|
| Hospital Charge Code |
4500815
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$310.50 |
| Max. Negotiated Rate |
$310.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.50
|
|
|
NM INDIUM III OXYQUIN / 5mCi
|
Facility
|
OP
|
$2,070.00
|
|
| Hospital Charge Code |
4500815
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$58.79 |
| Max. Negotiated Rate |
$1,035.00 |
| Rate for Payer: Aetna Commercial |
$786.60
|
| 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) PPO |
$527.85
|
| Rate for Payer: Cigna Commercial |
$1,035.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$538.20
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$310.50
|
| Rate for Payer: UnitedHealthcare Community & State |
$65.41
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$58.79
|
|
