|
BALLOON NANOCROSS PTA 3.0x120
|
Facility
|
IP
|
$1,538.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644449
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$372.34 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$307.72
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$372.34
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$230.79
|
|
|
BALLOON NANOCROSS PTA 3.0x120
|
Facility
|
OP
|
$1,538.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644449
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$43.70 |
| Max. Negotiated Rate |
$769.30 |
| Rate for Payer: Aetna Commercial |
$584.67
|
| Rate for Payer: Aetna Medicare Advantage |
$461.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$392.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$392.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$307.72
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$392.34
|
| Rate for Payer: Cigna Commercial |
$769.30
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$372.34
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$230.79
|
| Rate for Payer: UnitedHealthcare Community & State |
$48.62
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$43.70
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
IP
|
$1,852.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279A
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$277.83 |
| Max. Negotiated Rate |
$448.23 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$370.44
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$448.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$277.83
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
OP
|
$1,852.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279A
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.60 |
| Max. Negotiated Rate |
$926.10 |
| Rate for Payer: Aetna Commercial |
$703.84
|
| Rate for Payer: Aetna Medicare Advantage |
$555.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$472.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$472.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$370.44
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$472.31
|
| Rate for Payer: Cigna Commercial |
$926.10
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$448.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$277.83
|
| Rate for Payer: UnitedHealthcare Community & State |
$58.53
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$52.60
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
IP
|
$1,852.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$277.83 |
| Max. Negotiated Rate |
$448.23 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$370.44
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$448.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$277.83
|
|
|
BALLOON NANOCROSS PTA 3.0x150
|
Facility
|
OP
|
$1,852.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644279C
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.60 |
| Max. Negotiated Rate |
$926.10 |
| Rate for Payer: Aetna Commercial |
$703.84
|
| Rate for Payer: Aetna Medicare Advantage |
$555.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$472.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$472.31
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$370.44
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$472.31
|
| Rate for Payer: Cigna Commercial |
$926.10
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$448.23
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$277.83
|
| Rate for Payer: UnitedHealthcare Community & State |
$58.53
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$52.60
|
|
|
BALLOON NANOCROSS PTA 3.0x20MM
|
Facility
|
OP
|
$1,375.00
|
|
| Hospital Charge Code |
270644410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x20MM
|
Facility
|
IP
|
$1,375.00
|
|
| Hospital Charge Code |
270644410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x210
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x210
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644392S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x210
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644392S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x210
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x40MM
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x40MM
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x60MM
|
Facility
|
OP
|
$1,375.00
|
|
| Hospital Charge Code |
270671654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0x60MM
|
Facility
|
IP
|
$1,375.00
|
|
| Hospital Charge Code |
270671654
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0X60MM
|
Facility
|
OP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270671654S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$687.50 |
| Rate for Payer: Aetna Commercial |
$522.50
|
| Rate for Payer: Aetna Medicare Advantage |
$412.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$350.62
|
| Rate for Payer: Cigna Commercial |
$687.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
| Rate for Payer: UnitedHealthcare Community & State |
$43.45
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$39.05
|
|
|
BALLOON NANOCROSS PTA 3.0X60MM
|
Facility
|
IP
|
$1,375.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270671654S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.25 |
| Max. Negotiated Rate |
$332.75 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$275.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$332.75
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$206.25
|
|
|
BALLOON NANOCROSS PTA 3.0x80MM
|
Facility
|
IP
|
$1,538.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644448
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$372.34 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$307.72
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$372.34
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$230.79
|
|
|
BALLOON NANOCROSS PTA 3.0x80MM
|
Facility
|
IP
|
$1,538.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644448S
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$372.34 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$307.72
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$372.34
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$230.79
|
|
|
BALLOON NANOCROSS PTA 3.0x80MM
|
Facility
|
OP
|
$1,625.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644448N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$812.50 |
| Rate for Payer: Aetna Commercial |
$617.50
|
| Rate for Payer: Aetna Medicare Advantage |
$487.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$414.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$414.38
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$325.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$414.38
|
| Rate for Payer: Cigna Commercial |
$812.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$393.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$243.75
|
| Rate for Payer: UnitedHealthcare Community & State |
$51.35
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$46.15
|
|
|
BALLOON NANOCROSS PTA 3.0x80MM
|
Facility
|
IP
|
$1,625.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644448N
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$393.25 |
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$325.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$393.25
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$243.75
|
|
|
BALLOON NANOCROSS PTA 3.0x80MM
|
Facility
|
OP
|
$1,538.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
270644448
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$43.70 |
| Max. Negotiated Rate |
$769.30 |
| Rate for Payer: Aetna Commercial |
$584.67
|
| Rate for Payer: Aetna Medicare Advantage |
$461.58
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$392.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$392.34
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$307.72
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$392.34
|
| Rate for Payer: Cigna Commercial |
$769.30
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$372.34
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$230.79
|
| Rate for Payer: UnitedHealthcare Community & State |
$48.62
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$43.70
|
|
