Heights University Hospital

All Charges

Charge

Type

Setting

Price

FAM SES CHLD WO PT/30MIN MCAID

Facility

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4822614
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAMVIR 125MG

Facility

$5.00

Hospital Charge Code	60635408
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

FAMVIR 125MG

Facility

$5.00

Hospital Charge Code	60635408
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

FAMVIR 125 MG TABLET

Facility

$72.56

Service Code	NDC 78036615
Hospital Charge Code	60635411
Hospital Revenue Code	250
Min. Negotiated Rate	$10.88
Max. Negotiated Rate	$10.88
Rate for Payer: Qualcare PPO/HMO/WC	$10.88

FAMVIR 125 MG TABLET

Facility

$72.56

Service Code	NDC 78036615
Hospital Charge Code	60635411
Hospital Revenue Code	250
Min. Negotiated Rate	$9.43
Max. Negotiated Rate	$36.28
Rate for Payer: Aetna Commercial	$21.77
Rate for Payer: Aetna Medicare Advantage	$21.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.50
Rate for Payer: Cigna Commercial	$36.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.43
Rate for Payer: Oxford Commercial	$36.28
Rate for Payer: Qualcare PPO/HMO/WC	$10.88
Rate for Payer: UnitedHealthcare Commercial	$36.28

FAMVIR 500 TAB

Facility

$36.00

Hospital Charge Code	60635061
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$5.40
Rate for Payer: Qualcare PPO/HMO/WC	$5.40

FAMVIR 500 TAB

Facility

$36.00

Hospital Charge Code	60635061
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: Aetna Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.18
Rate for Payer: Cigna Commercial	$18.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.68
Rate for Payer: Oxford Commercial	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.40
Rate for Payer: UnitedHealthcare Commercial	$18.00

FANAPT 12MG

Facility

$46.15

Hospital Charge Code	60635750
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$23.07
Rate for Payer: Aetna Commercial	$13.85
Rate for Payer: Aetna Medicare Advantage	$13.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.77
Rate for Payer: Cigna Commercial	$23.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.00
Rate for Payer: Oxford Commercial	$23.07
Rate for Payer: Qualcare PPO/HMO/WC	$6.92
Rate for Payer: UnitedHealthcare Commercial	$23.07

FANAPT 12MG

Facility

$46.15

Hospital Charge Code	60635750
Hospital Revenue Code	250
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$6.92
Rate for Payer: Qualcare PPO/HMO/WC	$6.92

FANAPT 4MG

Facility

$46.15

Hospital Charge Code	60635751
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$23.07
Rate for Payer: Aetna Commercial	$13.85
Rate for Payer: Aetna Medicare Advantage	$13.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.77
Rate for Payer: Cigna Commercial	$23.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.00
Rate for Payer: Oxford Commercial	$23.07
Rate for Payer: Qualcare PPO/HMO/WC	$6.92
Rate for Payer: UnitedHealthcare Commercial	$23.07

FANAPT 4MG

Facility

$46.15

Hospital Charge Code	60635751
Hospital Revenue Code	250
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$6.92
Rate for Payer: Qualcare PPO/HMO/WC	$6.92

FANCONI ANEMIA DNA MUTATION

Facility

$1,025.00

Hospital Charge Code	3035125
Hospital Revenue Code	301
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$512.50
Rate for Payer: Aetna Commercial	$307.50
Rate for Payer: Aetna Medicare Advantage	$307.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$261.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$261.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$261.38
Rate for Payer: Cigna Commercial	$512.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$133.25
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$153.75
Rate for Payer: UnitedHealthcare Commercial	$114.00

FANCONI ANEMIA DNA MUTATION

Facility

$1,025.00

Hospital Charge Code	3035125
Hospital Revenue Code	301
Min. Negotiated Rate	$153.75
Max. Negotiated Rate	$153.75
Rate for Payer: Qualcare PPO/HMO/WC	$153.75

FASCIA LATA AMS 4 7 64350002

Facility

$3,218.45

Hospital Charge Code	270626777
Hospital Revenue Code	278
Min. Negotiated Rate	$482.77
Max. Negotiated Rate	$778.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$643.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$778.86
Rate for Payer: Qualcare PPO/HMO/WC	$482.77

FASCIA LATA AMS 4 7 64350002

Facility

$3,218.45

Hospital Charge Code	270626777
Hospital Revenue Code	278
Min. Negotiated Rate	$482.77
Max. Negotiated Rate	$1,609.22
Rate for Payer: Aetna Commercial	$965.53
Rate for Payer: Aetna Medicare Advantage	$965.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$820.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$820.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$643.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$820.70
Rate for Payer: Cigna Commercial	$1,609.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$778.86
Rate for Payer: Qualcare PPO/HMO/WC	$482.77

FASCIA LATA MENTOR 2X18 937202

Facility

$3,024.00

Hospital Charge Code	270611024
Hospital Revenue Code	278
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$731.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$604.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$731.81
Rate for Payer: Qualcare PPO/HMO/WC	$453.60

FASCIA LATA MENTOR 2X18 937202

Facility

$3,024.00

Hospital Charge Code	270611024
Hospital Revenue Code	278
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$1,512.00
Rate for Payer: Aetna Commercial	$907.20
Rate for Payer: Aetna Medicare Advantage	$907.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$771.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$771.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$604.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$771.12
Rate for Payer: Cigna Commercial	$1,512.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$731.81
Rate for Payer: Qualcare PPO/HMO/WC	$453.60

FASCIA LATA MENTOR 2X4 937200

Facility

$2,261.65

Hospital Charge Code	270611021
Hospital Revenue Code	278
Min. Negotiated Rate	$339.25
Max. Negotiated Rate	$547.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$452.33
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$547.32
Rate for Payer: Qualcare PPO/HMO/WC	$339.25

FASCIA LATA MENTOR 2X4 937200

Facility

$2,261.65

Hospital Charge Code	270611021
Hospital Revenue Code	278
Min. Negotiated Rate	$339.25
Max. Negotiated Rate	$1,130.83
Rate for Payer: Aetna Commercial	$678.50
Rate for Payer: Aetna Medicare Advantage	$678.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$576.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$576.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$452.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$576.72
Rate for Payer: Cigna Commercial	$1,130.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$547.32
Rate for Payer: Qualcare PPO/HMO/WC	$339.25

FASCIA LATA MENTOR 2X7 937227

Facility

$3,028.00

Hospital Charge Code	270611022
Hospital Revenue Code	278
Min. Negotiated Rate	$454.20
Max. Negotiated Rate	$732.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$605.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$732.78
Rate for Payer: Qualcare PPO/HMO/WC	$454.20

FASCIA LATA MENTOR 2X7 937227

Facility

$3,028.00

Hospital Charge Code	270611022
Hospital Revenue Code	278
Min. Negotiated Rate	$454.20
Max. Negotiated Rate	$1,514.00
Rate for Payer: Aetna Commercial	$908.40
Rate for Payer: Aetna Medicare Advantage	$908.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$772.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$772.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$605.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$772.14
Rate for Payer: Cigna Commercial	$1,514.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$732.78
Rate for Payer: Qualcare PPO/HMO/WC	$454.20

FASCIA LATA MENTOR 4X7 937201

Facility

$3,793.65

Hospital Charge Code	270611023
Hospital Revenue Code	278
Min. Negotiated Rate	$569.05
Max. Negotiated Rate	$1,896.83
Rate for Payer: Aetna Commercial	$1,138.10
Rate for Payer: Aetna Medicare Advantage	$1,138.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$967.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$967.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$758.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$967.38
Rate for Payer: Cigna Commercial	$1,896.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$918.06
Rate for Payer: Qualcare PPO/HMO/WC	$569.05

FASCIA LATA MENTOR 4X7 937201

Facility

$3,793.65

Hospital Charge Code	270611023
Hospital Revenue Code	278
Min. Negotiated Rate	$569.05
Max. Negotiated Rate	$918.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$758.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$918.06
Rate for Payer: Qualcare PPO/HMO/WC	$569.05

FASCIA LATA MENTOR 5X7 937245

Facility

$3,028.00

Hospital Charge Code	270611062
Hospital Revenue Code	278
Min. Negotiated Rate	$454.20
Max. Negotiated Rate	$732.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$605.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$732.78
Rate for Payer: Qualcare PPO/HMO/WC	$454.20

FASCIA LATA MENTOR 5X7 937245

Facility

$3,028.00

Hospital Charge Code	270611062
Hospital Revenue Code	278
Min. Negotiated Rate	$454.20
Max. Negotiated Rate	$1,514.00
Rate for Payer: Aetna Commercial	$908.40
Rate for Payer: Aetna Medicare Advantage	$908.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$772.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$772.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$605.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$772.14
Rate for Payer: Cigna Commercial	$1,514.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$732.78
Rate for Payer: Qualcare PPO/HMO/WC	$454.20

Know your out-of-pocket cost for care.

All Charges