Heights University Hospital

All Charges

Charge

Type

Setting

Price

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	73050810
Hospital Revenue Code	771
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$4.65
Rate for Payer: Qualcare PPO/HMO/WC	$4.65

IMM.ADM THRG 18YRS @ ADDL VAC

Facility

$31.00

Service Code	HCPCS 90461
Hospital Charge Code	83652293
Hospital Revenue Code	771
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$9.30
Rate for Payer: Aetna Medicare Advantage	$9.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.91
Rate for Payer: Cigna Commercial	$9.46
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.03
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$4.65
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	73050805
Hospital Revenue Code	771
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$12.30
Rate for Payer: Aetna Medicare Advantage	$12.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.46
Rate for Payer: Cigna Commercial	$26.31
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.33
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.15
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	83652291
Hospital Revenue Code	771
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: Qualcare PPO/HMO/WC	$6.15

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	73050805
Hospital Revenue Code	771
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: Qualcare PPO/HMO/WC	$6.15

IMM.ADM.THROUGH 18YRS.FST VACC

Facility

$41.00

Service Code	HCPCS 90460
Hospital Charge Code	83652291
Hospital Revenue Code	771
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$12.30
Rate for Payer: Aetna Medicare Advantage	$12.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.46
Rate for Payer: Cigna Commercial	$26.31
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.33
Rate for Payer: Oxford Commercial	$91.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.15
Rate for Payer: UnitedHealthcare Commercial	$103.00

IMM GLOB 50MG/ML 10GM/200ML

Facility

$9,460.40

Service Code	HCPCS J1568
Hospital Charge Code	60635794
Hospital Revenue Code	636
Min. Negotiated Rate	$1,419.06
Max. Negotiated Rate	$2,289.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,289.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,419.06

IMM GLOB 50MG/ML 10GM/200ML

Facility

$9,460.40

Service Code	HCPCS J1568
Hospital Charge Code	60635794
Hospital Revenue Code	636
Min. Negotiated Rate	$1,419.06
Max. Negotiated Rate	$2,838.12
Rate for Payer: Aetna Commercial	$2,838.12
Rate for Payer: Aetna Medicare Advantage	$2,838.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,412.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,412.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,412.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,289.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,419.06

IMM GLOB GAMM 5% 10GM 200ML VL

Facility

$3,241.70

Hospital Charge Code	606350916
Hospital Revenue Code	636
Min. Negotiated Rate	$486.25
Max. Negotiated Rate	$784.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$784.49
Rate for Payer: Qualcare PPO/HMO/WC	$486.25

IMM GLOB GAMM 5% 10GM 200ML VL

Facility

$3,241.70

Hospital Charge Code	606350916
Hospital Revenue Code	636
Min. Negotiated Rate	$486.25
Max. Negotiated Rate	$1,620.85
Rate for Payer: Aetna Commercial	$972.51
Rate for Payer: Aetna Medicare Advantage	$972.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$826.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$826.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$826.63
Rate for Payer: Cigna Commercial	$1,620.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$784.49
Rate for Payer: Qualcare PPO/HMO/WC	$486.25

IMM KNEE XX-LRG 22 1876-507-22

Facility

$135.00

Hospital Charge Code	270635397
Hospital Revenue Code	272
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$20.25
Rate for Payer: Qualcare PPO/HMO/WC	$20.25

IMM KNEE XX-LRG 22 1876-507-22

Facility

$135.00

Hospital Charge Code	270635397
Hospital Revenue Code	272
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: Aetna Medicare Advantage	$40.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.42
Rate for Payer: Cigna Commercial	$67.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.55
Rate for Payer: Oxford Commercial	$67.50
Rate for Payer: Qualcare PPO/HMO/WC	$20.25
Rate for Payer: UnitedHealthcare Commercial	$67.50

IMMOBILIZER HAND XL DISP

Facility

$151.33

Hospital Charge Code	270642434
Hospital Revenue Code	272
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$22.70
Rate for Payer: Qualcare PPO/HMO/WC	$22.70

IMMOBILIZER HAND XL DISP

Facility

$151.33

Hospital Charge Code	270642434
Hospital Revenue Code	272
Min. Negotiated Rate	$19.67
Max. Negotiated Rate	$75.67
Rate for Payer: Aetna Commercial	$45.40
Rate for Payer: Aetna Medicare Advantage	$45.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.59
Rate for Payer: Cigna Commercial	$75.67
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.67
Rate for Payer: Oxford Commercial	$75.67
Rate for Payer: Qualcare PPO/HMO/WC	$22.70
Rate for Payer: UnitedHealthcare Commercial	$75.67

IMMOBILIZER KNEE *******

Facility

$102.00

Hospital Charge Code	8001935
Hospital Revenue Code	279
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$15.30
Rate for Payer: Qualcare PPO/HMO/WC	$15.30

IMMOBILIZER KNEE *******

Facility

$102.00

Hospital Charge Code	8001935
Hospital Revenue Code	279
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: Aetna Medicare Advantage	$30.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.01
Rate for Payer: Cigna Commercial	$51.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.26
Rate for Payer: Oxford Commercial	$51.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.30
Rate for Payer: UnitedHealthcare Commercial	$51.00

IMMOBILIZER KNEE 16 UNIVERSAL

Facility

$51.90

Service Code	HCPCS L1830
Hospital Charge Code	270650067
Hospital Revenue Code	274
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$12.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$10.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.56
Rate for Payer: Qualcare PPO/HMO/WC	$7.79

IMMOBILIZER KNEE 16 UNIVERSAL

Facility

$51.90

Service Code	HCPCS L1830
Hospital Charge Code	270650067
Hospital Revenue Code	274
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$69.94
Rate for Payer: Aetna Commercial	$15.57
Rate for Payer: Aetna Medicare Advantage	$15.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$10.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.23
Rate for Payer: Cigna Commercial	$69.94
Rate for Payer: Cigna Medicare Advantage	$41.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.56
Rate for Payer: Qualcare PPO/HMO/WC	$7.79

IMMOBILIZER KNEE LG

Facility

$92.35

Hospital Charge Code	270302810
Hospital Revenue Code	270
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$46.17
Rate for Payer: Aetna Commercial	$27.70
Rate for Payer: Aetna Medicare Advantage	$27.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.55
Rate for Payer: Cigna Commercial	$46.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.01
Rate for Payer: Oxford Commercial	$46.17
Rate for Payer: Qualcare PPO/HMO/WC	$13.85
Rate for Payer: UnitedHealthcare Commercial	$46.17

IMMOBILIZER KNEE LG

Facility

$92.35

Hospital Charge Code	270302810
Hospital Revenue Code	270
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$13.85
Rate for Payer: Qualcare PPO/HMO/WC	$13.85

IMMOBILIZER KNEE MED

Facility

$127.25

Hospital Charge Code	270302820
Hospital Revenue Code	270
Min. Negotiated Rate	$16.54
Max. Negotiated Rate	$63.62
Rate for Payer: Aetna Commercial	$38.17
Rate for Payer: Aetna Medicare Advantage	$38.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$32.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$32.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$32.45
Rate for Payer: Cigna Commercial	$63.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.54
Rate for Payer: Oxford Commercial	$63.62
Rate for Payer: Qualcare PPO/HMO/WC	$19.09
Rate for Payer: UnitedHealthcare Commercial	$63.62

IMMOBILIZER KNEE MED

Facility

$127.25

Hospital Charge Code	270302820
Hospital Revenue Code	270
Min. Negotiated Rate	$19.09
Max. Negotiated Rate	$19.09
Rate for Payer: Qualcare PPO/HMO/WC	$19.09

IMMOBILIZER KNEE ONE SIZE 16

Facility

$80.55

Hospital Charge Code	270302805
Hospital Revenue Code	271
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$12.08
Rate for Payer: Qualcare PPO/HMO/WC	$12.08

IMMOBILIZER KNEE ONE SIZE 16

Facility

$80.55

Hospital Charge Code	270302805
Hospital Revenue Code	271
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$40.27
Rate for Payer: Aetna Commercial	$24.16
Rate for Payer: Aetna Medicare Advantage	$24.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.54
Rate for Payer: Cigna Commercial	$40.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.47
Rate for Payer: Oxford Commercial	$40.27
Rate for Payer: Qualcare PPO/HMO/WC	$12.08
Rate for Payer: UnitedHealthcare Commercial	$40.27

IMMOBILIZER KNEE ONE SIZE 20

Facility

$89.75

Hospital Charge Code	270302815
Hospital Revenue Code	272
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$13.46
Rate for Payer: Qualcare PPO/HMO/WC	$13.46

Know your out-of-pocket cost for care.

All Charges