Heights University Hospital

All Charges

Charge

Type

Setting

Price

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4517517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4504517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4546517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4510517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4510517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4822517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4518517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4824517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4511517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4535517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4535517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4511517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4504517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4527517
Hospital Revenue Code	916
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00

FAMILY TX W PT 50 MIN CHILD

Facility

$1,500.00

Service Code	HCPCS 90847
Hospital Charge Code	4832517
Hospital Revenue Code	916
Min. Negotiated Rate	$113.84
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$450.00
Rate for Payer: Aetna Medicare Advantage	$450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$382.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$382.50
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$195.00
Rate for Payer: Qualcare PPO/HMO/WC	$225.00
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAMOTIDINE 20 MG/ 2ML INJ

Facility

$5.16

Service Code	NDC 641602201
Hospital Charge Code	60629059
Hospital Revenue Code	250
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$0.77
Rate for Payer: Qualcare PPO/HMO/WC	$0.77

FAMOTIDINE 20 MG/ 2ML INJ

Facility

$5.16

Service Code	NDC 641602201
Hospital Charge Code	60629059
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna Commercial	$1.55
Rate for Payer: Aetna Medicare Advantage	$1.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.32
Rate for Payer: Cigna Commercial	$2.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.67
Rate for Payer: Oxford Commercial	$2.58
Rate for Payer: Qualcare PPO/HMO/WC	$0.77
Rate for Payer: UnitedHealthcare Commercial	$2.58

FAMOTIDINE 20 MG TAB

Facility

$11.59

Service Code	NDC 187442010
Hospital Charge Code	60629349
Hospital Revenue Code	250
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$5.79
Rate for Payer: Aetna Commercial	$3.48
Rate for Payer: Aetna Medicare Advantage	$3.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.96
Rate for Payer: Cigna Commercial	$5.79
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.51
Rate for Payer: Oxford Commercial	$5.79
Rate for Payer: Qualcare PPO/HMO/WC	$1.74
Rate for Payer: UnitedHealthcare Commercial	$5.79

FAMOTIDINE 20 MG TAB

Facility

$11.59

Service Code	NDC 187442010
Hospital Charge Code	60629349
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$1.74
Rate for Payer: Qualcare PPO/HMO/WC	$1.74

FAMOTIDINE 40MG/5ML

Facility

$509.75

Hospital Charge Code	6063943107
Hospital Revenue Code	250
Min. Negotiated Rate	$66.27
Max. Negotiated Rate	$254.88
Rate for Payer: Aetna Commercial	$152.93
Rate for Payer: Aetna Medicare Advantage	$152.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$129.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$129.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$129.99
Rate for Payer: Cigna Commercial	$254.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$66.27
Rate for Payer: Oxford Commercial	$254.88
Rate for Payer: Qualcare PPO/HMO/WC	$76.46
Rate for Payer: UnitedHealthcare Commercial	$254.88

FAMOTIDINE 40MG/5ML

Facility

$509.75

Hospital Charge Code	6063943107
Hospital Revenue Code	250
Min. Negotiated Rate	$76.46
Max. Negotiated Rate	$76.46
Rate for Payer: Qualcare PPO/HMO/WC	$76.46

FAMOTIDINE 40 MG/5 ML ORAL SUS

Facility

$118.46

Service Code	NDC 68382044405
Hospital Charge Code	6063943199
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$59.23
Rate for Payer: Aetna Commercial	$35.54
Rate for Payer: Aetna Medicare Advantage	$35.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.21
Rate for Payer: Cigna Commercial	$59.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.40
Rate for Payer: Oxford Commercial	$59.23
Rate for Payer: Qualcare PPO/HMO/WC	$17.77
Rate for Payer: UnitedHealthcare Commercial	$59.23

FAMOTIDINE 40 MG/5 ML ORAL SUS

Facility

$118.46

Service Code	NDC 68382044405
Hospital Charge Code	6063943199
Hospital Revenue Code	250
Min. Negotiated Rate	$17.77
Max. Negotiated Rate	$17.77
Rate for Payer: Qualcare PPO/HMO/WC	$17.77

FAMOTIDINE INJ 20MG

Facility

$21.15

Hospital Charge Code	6016356
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$10.57
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Aetna Medicare Advantage	$6.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.39
Rate for Payer: Cigna Commercial	$10.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.75
Rate for Payer: Oxford Commercial	$10.57
Rate for Payer: Qualcare PPO/HMO/WC	$3.17
Rate for Payer: UnitedHealthcare Commercial	$10.57

FAMOTIDINE INJ 20MG

Facility

$21.15

Hospital Charge Code	6016356
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.17
Rate for Payer: Qualcare PPO/HMO/WC	$3.17

Know your out-of-pocket cost for care.

All Charges