|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270684979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.33
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270684979
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x40x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270641871
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x40x80
|
Facility
|
OP
|
$575.00
|
|
| Hospital Charge Code |
270671616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.33
|
|
|
BALLOON EVERCROSS PTA 6x40x80
|
Facility
|
IP
|
$575.00
|
|
| Hospital Charge Code |
270671616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x60x135
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270639644N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.33
|
|
|
BALLOON EVERCROSS PTA 6x60x80
|
Facility
|
IP
|
$575.00
|
|
| Hospital Charge Code |
270671617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x60x80
|
Facility
|
OP
|
$575.00
|
|
| Hospital Charge Code |
270671617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.33
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$139.15 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Aetna Commercial |
$218.50
|
| Rate for Payer: Aetna Medicare Advantage |
$172.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$146.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$115.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$146.62
|
| Rate for Payer: Cigna Commercial |
$287.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$139.15
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$86.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.17
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.33
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
OP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$340.55 |
| Rate for Payer: Aetna Commercial |
$258.82
|
| Rate for Payer: Aetna Medicare Advantage |
$204.33
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$173.68
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$173.68
|
| Rate for Payer: Cigna Commercial |
$340.55
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
| Rate for Payer: UnitedHealthcare Community & State |
$21.52
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$19.34
|
|
|
BALLOON EVERCROSS PTA 6x80x135
|
Facility
|
IP
|
$681.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$102.17 |
| Max. Negotiated Rate |
$164.83 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$136.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$164.83
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$102.17
|
|
|
BALLOON EVERCROSS PTA 6x80x80
|
Facility
|
OP
|
$857.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270671618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$428.75 |
| Rate for Payer: Aetna Commercial |
$325.85
|
| Rate for Payer: Aetna Medicare Advantage |
$257.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$218.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$218.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$171.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$218.66
|
| Rate for Payer: Cigna Commercial |
$428.75
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$207.51
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$128.62
|
| Rate for Payer: UnitedHealthcare Community & State |
$27.10
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$24.35
|
|
|
BALLOON EVERCROSS PTA 6x80x80
|
Facility
|
IP
|
$857.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270671618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$128.62 |
| Max. Negotiated Rate |
$207.51 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$171.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$207.51
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$128.62
|
|
|
BALLOON EVERCROSS PTA 6X80X80
|
Facility
|
IP
|
$857.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270671618S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$128.62 |
| Max. Negotiated Rate |
$207.51 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$171.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$207.51
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$128.62
|
|
