Heights University Hospital

All Charges

Charge

Type

Setting

Price

INDIV PT THER OP 45-50M W/ E/M

Facility

$409.00

Service Code	HCPCS 90807
Hospital Charge Code	9310083
Hospital Revenue Code	914
Min. Negotiated Rate	$61.35
Max. Negotiated Rate	$61.35
Rate for Payer: Qualcare PPO/HMO/WC	$61.35

INDIV PT THER OP 45-50M W/O EM

Facility

$449.95

Service Code	HCPCS 90806
Hospital Charge Code	9310080
Hospital Revenue Code	914
Min. Negotiated Rate	$67.49
Max. Negotiated Rate	$67.49
Rate for Payer: Qualcare PPO/HMO/WC	$67.49

INDIV PT THER OP 45-50M W/O EM

Facility

$449.95

Service Code	HCPCS 90806
Hospital Charge Code	9310080
Hospital Revenue Code	914
Min. Negotiated Rate	$58.49
Max. Negotiated Rate	$224.97
Rate for Payer: Aetna Commercial	$134.99
Rate for Payer: Aetna Medicare Advantage	$134.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$114.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$114.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$114.74
Rate for Payer: Cigna Commercial	$224.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$58.49
Rate for Payer: Qualcare PPO/HMO/WC	$67.49

INDIV.THERAPY 20-30 MTS

Facility

$1,296.00

Service Code	HCPCS 90804
Hospital Charge Code	84504020
Hospital Revenue Code	914
Min. Negotiated Rate	$168.48
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: Aetna Medicare Advantage	$388.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$330.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$330.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$330.48
Rate for Payer: Cigna Commercial	$648.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$168.48
Rate for Payer: Qualcare PPO/HMO/WC	$194.40

INDIV.THERAPY 20-30 MTS

Facility

$1,296.00

Service Code	HCPCS 90804
Hospital Charge Code	84504020
Hospital Revenue Code	914
Min. Negotiated Rate	$194.40
Max. Negotiated Rate	$194.40
Rate for Payer: Qualcare PPO/HMO/WC	$194.40

INDOCIN/50MG/EACH

Facility

$8.00

Hospital Charge Code	60633179
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: Aetna Medicare Advantage	$2.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.04
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.04
Rate for Payer: Oxford Commercial	$4.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.20
Rate for Payer: UnitedHealthcare Commercial	$4.00

INDOCIN/50MG/EACH

Facility

$8.00

Hospital Charge Code	60633179
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

INDOCIN 50MG SUPP

Facility

$1,136.52

Service Code	NDC 69344010233
Hospital Charge Code	60630246
Hospital Revenue Code	250
Min. Negotiated Rate	$170.48
Max. Negotiated Rate	$170.48
Rate for Payer: Qualcare PPO/HMO/WC	$170.48

INDOCIN 50MG SUPP

Facility

$1,136.52

Service Code	NDC 69344010233
Hospital Charge Code	60630246
Hospital Revenue Code	250
Min. Negotiated Rate	$147.75
Max. Negotiated Rate	$568.26
Rate for Payer: Aetna Commercial	$340.96
Rate for Payer: Aetna Medicare Advantage	$340.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$289.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$289.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$289.81
Rate for Payer: Cigna Commercial	$568.26
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$147.75
Rate for Payer: Oxford Commercial	$568.26
Rate for Payer: Qualcare PPO/HMO/WC	$170.48
Rate for Payer: UnitedHealthcare Commercial	$568.26

INDOCIN SR/75MG/CAP

Facility

$8.00

Hospital Charge Code	60633180
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

INDOCIN SR/75MG/CAP

Facility

$8.00

Hospital Charge Code	60633180
Hospital Revenue Code	250
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: Aetna Medicare Advantage	$2.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.04
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.04
Rate for Payer: Oxford Commercial	$4.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.20
Rate for Payer: UnitedHealthcare Commercial	$4.00

INDOCYANINE GREEN

Facility

$916.02

Service Code	NDC 17478070102
Hospital Charge Code	60635705
Hospital Revenue Code	250
Min. Negotiated Rate	$119.08
Max. Negotiated Rate	$458.01
Rate for Payer: Aetna Commercial	$274.81
Rate for Payer: Aetna Medicare Advantage	$274.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$233.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$233.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$233.59
Rate for Payer: Cigna Commercial	$458.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$119.08
Rate for Payer: Oxford Commercial	$458.01
Rate for Payer: Qualcare PPO/HMO/WC	$137.40
Rate for Payer: UnitedHealthcare Commercial	$458.01

INDOCYANINE GREEN

Facility

$916.02

Service Code	NDC 17478070102
Hospital Charge Code	60635705
Hospital Revenue Code	250
Min. Negotiated Rate	$137.40
Max. Negotiated Rate	$137.40
Rate for Payer: Qualcare PPO/HMO/WC	$137.40

INDOMETHACIN 25 MG CAP

Facility

$4.00

Service Code	NDC 93402901
Hospital Charge Code	60627684
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

INDOMETHACIN 25 MG CAP

Facility

$4.00

Service Code	NDC 93402901
Hospital Charge Code	60627684
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633181
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

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633182
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633181
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

INDOMETHACIN/25MG/CAP

Facility

$4.00

Hospital Charge Code	60633182
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

INDOMETHACIN/50MG/CAP

Facility

$3.00

Hospital Charge Code	60633183
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

INDOMETHACIN/50MG/CAP

Facility

$3.00

Hospital Charge Code	60633183
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

INDOMETHACIN 50MG CAPSULE

Facility

$4.56

Service Code	NDC 51079019120
Hospital Charge Code	60632345
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Qualcare PPO/HMO/WC	$0.68

INDOMETHACIN 50MG CAPSULE

Facility

$4.56

Service Code	NDC 51079019120
Hospital Charge Code	60632345
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$2.28
Rate for Payer: Aetna Commercial	$1.37
Rate for Payer: Aetna Medicare Advantage	$1.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.16
Rate for Payer: Cigna Commercial	$2.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.59
Rate for Payer: Oxford Commercial	$2.28
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$2.28

INDOMETHACIN 75 MG CER

Facility

$13.65

Hospital Charge Code	60628820
Hospital Revenue Code	250
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$6.83
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: Aetna Medicare Advantage	$4.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.48
Rate for Payer: Cigna Commercial	$6.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.77
Rate for Payer: Oxford Commercial	$6.83
Rate for Payer: Qualcare PPO/HMO/WC	$2.05
Rate for Payer: UnitedHealthcare Commercial	$6.83

INDOMETHACIN 75 MG CER

Facility

$13.65

Hospital Charge Code	60628820
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.05
Rate for Payer: Qualcare PPO/HMO/WC	$2.05

Know your out-of-pocket cost for care.

All Charges