Heights University Hospital

All Charges

Charge

Type

Setting

Price

FORG BODY REM EXT AUD CNL

Facility

$8,054.80

Service Code	HCPCS 69205
Hospital Charge Code	5790220
Hospital Revenue Code	450
Min. Negotiated Rate	$1,208.22
Max. Negotiated Rate	$1,208.22
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22

FORG BODY REM EXT AUD CNL

Facility

$8,054.80

Service Code	HCPCS 69205
Hospital Charge Code	5790220
Hospital Revenue Code	450
Min. Negotiated Rate	$46.31
Max. Negotiated Rate	$3,933.12
Rate for Payer: Aetna Commercial	$2,416.44
Rate for Payer: Aetna Medicare Advantage	$2,416.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,053.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,053.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$46.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,053.97
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,047.12
Rate for Payer: Qualcare PPO/HMO/WC	$1,208.22

FORMAGRAFT LARGE

Facility

$9,000.00

Hospital Charge Code	270663769
Hospital Revenue Code	270
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$1,350.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

FORMAGRAFT LARGE

Facility

$9,000.00

Hospital Charge Code	270663769
Hospital Revenue Code	270
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$4,500.00
Rate for Payer: Aetna Commercial	$2,700.00
Rate for Payer: Aetna Medicare Advantage	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,295.00
Rate for Payer: Cigna Commercial	$4,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,170.00
Rate for Payer: Oxford Commercial	$4,500.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00
Rate for Payer: UnitedHealthcare Commercial	$4,500.00

FORMAGRAFT XL BLOCKS, LARGE

Facility

$11,465.00

Hospital Charge Code	270667570
Hospital Revenue Code	278
Min. Negotiated Rate	$1,719.75
Max. Negotiated Rate	$5,732.50
Rate for Payer: Aetna Commercial	$3,439.50
Rate for Payer: Aetna Medicare Advantage	$3,439.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,923.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,923.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,293.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,923.57
Rate for Payer: Cigna Commercial	$5,732.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,774.53
Rate for Payer: Qualcare PPO/HMO/WC	$1,719.75

FORMAGRAFT XL BLOCKS, LARGE

Facility

$11,465.00

Hospital Charge Code	270667570
Hospital Revenue Code	278
Min. Negotiated Rate	$1,719.75
Max. Negotiated Rate	$2,774.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,293.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,774.53
Rate for Payer: Qualcare PPO/HMO/WC	$1,719.75

FORMALDEHYDE 10% 100ML-BLADDER

Facility

$181.15

Hospital Charge Code	6010227
Hospital Revenue Code	251
Min. Negotiated Rate	$27.17
Max. Negotiated Rate	$27.17
Rate for Payer: Qualcare PPO/HMO/WC	$27.17

FORMALDEHYDE 10% 100ML-BLADDER

Facility

$181.15

Hospital Charge Code	6010227
Hospital Revenue Code	251
Min. Negotiated Rate	$23.55
Max. Negotiated Rate	$90.58
Rate for Payer: Aetna Commercial	$54.34
Rate for Payer: Aetna Medicare Advantage	$54.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.19
Rate for Payer: Cigna Commercial	$90.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.55
Rate for Payer: Oxford Commercial	$90.58
Rate for Payer: Qualcare PPO/HMO/WC	$27.17
Rate for Payer: UnitedHealthcare Commercial	$90.58

FOR ODDS AND ENDS

Facility

$200.00

Hospital Charge Code	270666777
Hospital Revenue Code	270
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$60.00
Rate for Payer: Aetna Medicare Advantage	$60.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.00
Rate for Payer: Cigna Commercial	$100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.00
Rate for Payer: Oxford Commercial	$100.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00
Rate for Payer: UnitedHealthcare Commercial	$100.00

FOR ODDS AND ENDS

Facility

$200.00

Hospital Charge Code	270666777
Hospital Revenue Code	270
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00

FORTAZ 1GM/50ML

Facility

$83.00

Hospital Charge Code	60635026
Hospital Revenue Code	250
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$41.50
Rate for Payer: Aetna Commercial	$24.90
Rate for Payer: Aetna Medicare Advantage	$24.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.16
Rate for Payer: Cigna Commercial	$41.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.79
Rate for Payer: Oxford Commercial	$41.50
Rate for Payer: Qualcare PPO/HMO/WC	$12.45
Rate for Payer: UnitedHealthcare Commercial	$41.50

FORTAZ 1GM/50ML

Facility

$83.00

Hospital Charge Code	60635026
Hospital Revenue Code	250
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$12.45
Rate for Payer: Qualcare PPO/HMO/WC	$12.45

FORTAZ/1GM/ADD DEX

Facility

$107.00

Hospital Charge Code	60634833
Hospital Revenue Code	250
Min. Negotiated Rate	$16.05
Max. Negotiated Rate	$16.05
Rate for Payer: Qualcare PPO/HMO/WC	$16.05

FORTAZ/1GM/ADD DEX

Facility

$107.00

Hospital Charge Code	60634833
Hospital Revenue Code	250
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$53.50
Rate for Payer: Aetna Commercial	$32.10
Rate for Payer: Aetna Medicare Advantage	$32.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.29
Rate for Payer: Cigna Commercial	$53.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.91
Rate for Payer: Oxford Commercial	$53.50
Rate for Payer: Qualcare PPO/HMO/WC	$16.05
Rate for Payer: UnitedHealthcare Commercial	$53.50

FORTAZ/1GM/ADD SALINE

Facility

$79.00

Hospital Charge Code	60634834
Hospital Revenue Code	250
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$39.50
Rate for Payer: Aetna Commercial	$23.70
Rate for Payer: Aetna Medicare Advantage	$23.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.14
Rate for Payer: Cigna Commercial	$39.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.27
Rate for Payer: Oxford Commercial	$39.50
Rate for Payer: Qualcare PPO/HMO/WC	$11.85
Rate for Payer: UnitedHealthcare Commercial	$39.50

FORTAZ/1GM/ADD SALINE

Facility

$79.00

Hospital Charge Code	60634834
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$11.85
Rate for Payer: Qualcare PPO/HMO/WC	$11.85

FORTAZ 2GM/50ML

Facility

$110.00

Hospital Charge Code	60635027
Hospital Revenue Code	250
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$16.50
Rate for Payer: Qualcare PPO/HMO/WC	$16.50

FORTAZ 2GM/50ML

Facility

$110.00

Hospital Charge Code	60635027
Hospital Revenue Code	250
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$33.00
Rate for Payer: Aetna Medicare Advantage	$33.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.05
Rate for Payer: Cigna Commercial	$55.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.30
Rate for Payer: Oxford Commercial	$55.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.50
Rate for Payer: UnitedHealthcare Commercial	$55.00

FORTAZ/2GM/ADD DEX

Facility

$181.00

Hospital Charge Code	60634835
Hospital Revenue Code	250
Min. Negotiated Rate	$23.53
Max. Negotiated Rate	$90.50
Rate for Payer: Aetna Commercial	$54.30
Rate for Payer: Aetna Medicare Advantage	$54.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.16
Rate for Payer: Cigna Commercial	$90.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.53
Rate for Payer: Oxford Commercial	$90.50
Rate for Payer: Qualcare PPO/HMO/WC	$27.15
Rate for Payer: UnitedHealthcare Commercial	$90.50

FORTAZ/2GM/ADD DEX

Facility

$181.00

Hospital Charge Code	60634835
Hospital Revenue Code	250
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$27.15
Rate for Payer: Qualcare PPO/HMO/WC	$27.15

FORTAZ/2GM/ADD SALINE

Facility

$181.00

Hospital Charge Code	60634836
Hospital Revenue Code	250
Min. Negotiated Rate	$23.53
Max. Negotiated Rate	$90.50
Rate for Payer: Aetna Commercial	$54.30
Rate for Payer: Aetna Medicare Advantage	$54.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$46.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$46.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$46.16
Rate for Payer: Cigna Commercial	$90.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.53
Rate for Payer: Oxford Commercial	$90.50
Rate for Payer: Qualcare PPO/HMO/WC	$27.15
Rate for Payer: UnitedHealthcare Commercial	$90.50

FORTAZ/2GM/ADD SALINE

Facility

$181.00

Hospital Charge Code	60634836
Hospital Revenue Code	250
Min. Negotiated Rate	$27.15
Max. Negotiated Rate	$27.15
Rate for Payer: Qualcare PPO/HMO/WC	$27.15

FORTAZ/500MG

Facility

$34.00

Hospital Charge Code	60633013
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Qualcare PPO/HMO/WC	$5.10

FORTAZ/500MG

Facility

$34.00

Hospital Charge Code	60633013
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Medicare Advantage	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.67
Rate for Payer: Cigna Commercial	$17.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.42
Rate for Payer: Oxford Commercial	$17.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.10
Rate for Payer: UnitedHealthcare Commercial	$17.00

FORTAZ/6GM

Facility

$490.00

Hospital Charge Code	60633015
Hospital Revenue Code	250
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$73.50
Rate for Payer: Qualcare PPO/HMO/WC	$73.50

Know your out-of-pocket cost for care.

All Charges