Heights University Hospital

All Charges

Charge

Type

Setting

Price

DIHYDROTERTOSTERONE 1-2

Facility

$179.00

Service Code	HCPCS 80327
Hospital Charge Code	3000602
Hospital Revenue Code	301
Min. Negotiated Rate	$26.85
Max. Negotiated Rate	$26.85
Rate for Payer: Qualcare PPO/HMO/WC	$26.85

DIHYDROTESTOSTERONE

Facility

$182.80

Service Code	HCPCS 80327
Hospital Charge Code	38472937
Hospital Revenue Code	301
Min. Negotiated Rate	$27.42
Max. Negotiated Rate	$27.42
Rate for Payer: Qualcare PPO/HMO/WC	$27.42

DIHYDROTESTOSTERONE

Facility

$182.80

Service Code	HCPCS 80327
Hospital Charge Code	38472937
Hospital Revenue Code	301
Min. Negotiated Rate	$23.76
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$54.84
Rate for Payer: Aetna Medicare Advantage	$54.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.61
Rate for Payer: Cigna Commercial	$91.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.76
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.42
Rate for Payer: UnitedHealthcare Commercial	$114.00

DIHYDROTESTOSTERONE,LC/MS

Facility

$390.00

Service Code	HCPCS 80327
Hospital Charge Code	39900072
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DIHYDROTESTOSTERONE,LC/MS

Facility

$390.00

Service Code	HCPCS 80327
Hospital Charge Code	39900072
Hospital Revenue Code	301
Min. Negotiated Rate	$50.70
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$117.00
Rate for Payer: Aetna Medicare Advantage	$117.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$114.00

DILANTIN-125/125MG/5ML

Facility

$5.00

Hospital Charge Code	60632846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.65
Rate for Payer: Oxford Commercial	$2.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$2.50

DILANTIN-125/125MG/5ML

Facility

$5.00

Hospital Charge Code	60632846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

DILANTIN/50MG/1ML

Facility

$17.00

Hospital Charge Code	60632844
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna Commercial	$5.10
Rate for Payer: Aetna Medicare Advantage	$5.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.33
Rate for Payer: Cigna Commercial	$8.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.21
Rate for Payer: Oxford Commercial	$8.50
Rate for Payer: Qualcare PPO/HMO/WC	$2.55
Rate for Payer: UnitedHealthcare Commercial	$8.50

DILANTIN/50MG/1ML

Facility

$17.00

Hospital Charge Code	60632844
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Qualcare PPO/HMO/WC	$2.55

DILANTIN KAPSEAL/100MG/1C

Facility

$4.00

Hospital Charge Code	60632845
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

DILANTIN KAPSEAL/100MG/1C

Facility

$4.00

Hospital Charge Code	60632845
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

DILANTIN (PHENYTOIN)

Facility

$303.00

Service Code	HCPCS 80185
Hospital Charge Code	38472536
Hospital Revenue Code	301
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$42.93
Rate for Payer: Aetna Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$35.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.55
Rate for Payer: Cigna Commercial	$13.25
Rate for Payer: Cigna Medicare Advantage	$6.62
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.39
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$45.45
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$14.04
Rate for Payer: Wellcare Medicare Advantage	$13.25

DILANTIN (PHENYTOIN)

Facility

$303.00

Service Code	HCPCS 80185
Hospital Charge Code	38472536
Hospital Revenue Code	301
Min. Negotiated Rate	$45.45
Max. Negotiated Rate	$45.45
Rate for Payer: Qualcare PPO/HMO/WC	$45.45

DILANTIN PHENYTOIN

Facility

$390.00

Service Code	HCPCS 80185
Hospital Charge Code	3003977
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DILANTIN PHENYTOIN

Facility

$390.00

Service Code	HCPCS 80185
Hospital Charge Code	3003977
Hospital Revenue Code	301
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$42.93
Rate for Payer: Aetna Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$35.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.55
Rate for Payer: Cigna Commercial	$13.25
Rate for Payer: Cigna Medicare Advantage	$6.62
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$14.04
Rate for Payer: Wellcare Medicare Advantage	$13.25

DILANTIN (PHENYTOIN) FREE

Facility

$133.65

Service Code	HCPCS 80186
Hospital Charge Code	3003978
Hospital Revenue Code	301
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$20.05
Rate for Payer: Qualcare PPO/HMO/WC	$20.05

DILANTIN (PHENYTOIN) FREE

Facility

$133.65

Service Code	HCPCS 80186
Hospital Charge Code	3003978
Hospital Revenue Code	301
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$44.58
Rate for Payer: Aetna Medicare Advantage	$13.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$50.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$50.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$35.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$50.42
Rate for Payer: Cigna Commercial	$13.76
Rate for Payer: Cigna Medicare Advantage	$6.88
Rate for Payer: Clover Medicare Advantage	$13.07
Rate for Payer: EmblemHealth Commercial	$41.28
Rate for Payer: Humana Medicare Advantage	$14.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.37
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$20.05
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.76
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$14.59
Rate for Payer: Wellcare Medicare Advantage	$13.76

DILANTIN SUSP 30/8OZ

Facility

$17.00

Hospital Charge Code	60634580
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Qualcare PPO/HMO/WC	$2.55

DILANTIN SUSP 30/8OZ

Facility

$17.00

Hospital Charge Code	60634580
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna Commercial	$5.10
Rate for Payer: Aetna Medicare Advantage	$5.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.33
Rate for Payer: Cigna Commercial	$8.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.21
Rate for Payer: Oxford Commercial	$8.50
Rate for Payer: Qualcare PPO/HMO/WC	$2.55
Rate for Payer: UnitedHealthcare Commercial	$8.50

DILANTIN SYSP 125/18OZ

Facility

$16.00

Hospital Charge Code	60634579
Hospital Revenue Code	250
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Aetna Medicare Advantage	$4.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.08
Rate for Payer: Cigna Commercial	$8.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.08
Rate for Payer: Oxford Commercial	$8.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.40
Rate for Payer: UnitedHealthcare Commercial	$8.00

DILANTIN SYSP 125/18OZ

Facility

$16.00

Hospital Charge Code	60634579
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: Qualcare PPO/HMO/WC	$2.40

DILATE ANAL SPHINCTER UNDER AN

Facility

$17,147.43

Service Code	HCPCS 45905
Hospital Charge Code	16000748
Hospital Revenue Code	360
Min. Negotiated Rate	$2,572.11
Max. Negotiated Rate	$2,572.11
Rate for Payer: Qualcare PPO/HMO/WC	$2,572.11

DILATE ANAL SPHINCTER UNDER AN

Facility

$17,147.43

Service Code	HCPCS 45905
Hospital Charge Code	16000748
Hospital Revenue Code	360
Min. Negotiated Rate	$1,864.00
Max. Negotiated Rate	$5,144.23
Rate for Payer: Aetna Commercial	$5,144.23
Rate for Payer: Aetna Medicare Advantage	$5,144.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,372.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,372.59
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	$4,372.59
Rate for Payer: Cigna Commercial	$2,849.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,229.17
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,572.11
Rate for Payer: UnitedHealthcare Commercial	$3,687.00

DILATE BILIARY DUCT/AMPULLA

Facility

$8,460.00

Service Code	HCPCS 47543
Hospital Charge Code	404647543
Hospital Revenue Code	361
Min. Negotiated Rate	$1,269.00
Max. Negotiated Rate	$1,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,269.00

DILATE BILIARY DUCT/AMPULLA

Facility

$8,460.00

Service Code	HCPCS 47543
Hospital Charge Code	404647543
Hospital Revenue Code	361
Min. Negotiated Rate	$132.07
Max. Negotiated Rate	$2,538.00
Rate for Payer: Aetna Commercial	$2,538.00
Rate for Payer: Aetna Medicare Advantage	$2,538.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,157.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,157.30
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	$2,157.30
Rate for Payer: Cigna Commercial	$132.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,099.80
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,269.00
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

Know your out-of-pocket cost for care.

All Charges