Heights University Hospital

All Charges

Charge

Type

Setting

Price

IR-INJ FOR SIALOGRAPH-BIL

Facility

$793.00

Service Code	HCPCS 4255050
Hospital Charge Code	2690590
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPH-BIL

Facility

$793.00

Service Code	HCPCS 4255050
Hospital Charge Code	7411816
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPH-BIL

Facility

$793.00

Service Code	HCPCS 4255050
Hospital Charge Code	2690590
Hospital Revenue Code	761
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$396.50
Rate for Payer: Aetna Commercial	$237.90
Rate for Payer: Aetna Medicare Advantage	$237.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$202.22
Rate for Payer: Cigna Commercial	$396.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$103.09
Rate for Payer: Oxford Commercial	$396.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.95
Rate for Payer: UnitedHealthcare Commercial	$396.50

IR-INJ FOR SIALOGRAPHY-LT

Facility

$793.00

Service Code	HCPCS 42550LT
Hospital Charge Code	2691510
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPHY-LT

Facility

$793.00

Service Code	HCPCS 42550LT
Hospital Charge Code	7411952
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPHY-LT

Facility

$793.00

Service Code	HCPCS 42550LT
Hospital Charge Code	7411952
Hospital Revenue Code	761
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$396.50
Rate for Payer: Aetna Commercial	$237.90
Rate for Payer: Aetna Medicare Advantage	$237.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$202.22
Rate for Payer: Cigna Commercial	$396.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$103.09
Rate for Payer: Oxford Commercial	$396.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.95
Rate for Payer: UnitedHealthcare Commercial	$396.50

IR-INJ FOR SIALOGRAPHY-LT

Facility

$793.00

Service Code	HCPCS 42550LT
Hospital Charge Code	2691510
Hospital Revenue Code	761
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$396.50
Rate for Payer: Aetna Commercial	$237.90
Rate for Payer: Aetna Medicare Advantage	$237.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$202.22
Rate for Payer: Cigna Commercial	$396.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$103.09
Rate for Payer: Oxford Commercial	$396.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.95
Rate for Payer: UnitedHealthcare Commercial	$396.50

IR-INJ FOR SIALOGRAPHY-RT

Facility

$793.00

Service Code	HCPCS 42550RT
Hospital Charge Code	2691515
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPHY-RT

Facility

$793.00

Service Code	HCPCS 42550RT
Hospital Charge Code	2691515
Hospital Revenue Code	761
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$396.50
Rate for Payer: Aetna Commercial	$237.90
Rate for Payer: Aetna Medicare Advantage	$237.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$202.22
Rate for Payer: Cigna Commercial	$396.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$103.09
Rate for Payer: Oxford Commercial	$396.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.95
Rate for Payer: UnitedHealthcare Commercial	$396.50

IR-INJ FOR SIALOGRAPHY-RT

Facility

$793.00

Service Code	HCPCS 42550RT
Hospital Charge Code	7411953
Hospital Revenue Code	761
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$118.95
Rate for Payer: Qualcare PPO/HMO/WC	$118.95

IR-INJ FOR SIALOGRAPHY-RT

Facility

$793.00

Service Code	HCPCS 42550RT
Hospital Charge Code	7411953
Hospital Revenue Code	761
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$396.50
Rate for Payer: Aetna Commercial	$237.90
Rate for Payer: Aetna Medicare Advantage	$237.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$202.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$202.22
Rate for Payer: Cigna Commercial	$396.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$103.09
Rate for Payer: Oxford Commercial	$396.50
Rate for Payer: Qualcare PPO/HMO/WC	$118.95
Rate for Payer: UnitedHealthcare Commercial	$396.50

IR-INJ FOR URETOPYELOG-LT

Facility

$942.00

Service Code	HCPCS 50690LT
Hospital Charge Code	7411980
Hospital Revenue Code	761
Min. Negotiated Rate	$122.46
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: Aetna Medicare Advantage	$282.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$240.21
Rate for Payer: Cigna Commercial	$471.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$122.46
Rate for Payer: Oxford Commercial	$471.00
Rate for Payer: Qualcare PPO/HMO/WC	$141.30
Rate for Payer: UnitedHealthcare Commercial	$471.00

IR-INJ FOR URETOPYELOG-LT

Facility

$942.00

Service Code	HCPCS 50690LT
Hospital Charge Code	2691700
Hospital Revenue Code	761
Min. Negotiated Rate	$122.46
Max. Negotiated Rate	$471.00
Rate for Payer: Oxford Commercial	$471.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: Aetna Medicare Advantage	$282.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$240.21
Rate for Payer: Cigna Commercial	$471.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$122.46
Rate for Payer: Qualcare PPO/HMO/WC	$141.30
Rate for Payer: UnitedHealthcare Commercial	$471.00

IR-INJ FOR URETOPYELOG-LT

Facility

$942.00

Service Code	HCPCS 50690LT
Hospital Charge Code	7411980
Hospital Revenue Code	761
Min. Negotiated Rate	$141.30
Max. Negotiated Rate	$141.30
Rate for Payer: Qualcare PPO/HMO/WC	$141.30

IR-INJ FOR URETOPYELOG-LT

Facility

$942.00

Service Code	HCPCS 50690LT
Hospital Charge Code	2691700
Hospital Revenue Code	761
Min. Negotiated Rate	$141.30
Max. Negotiated Rate	$141.30
Rate for Payer: Qualcare PPO/HMO/WC	$141.30

IR-INJ FOR URETOPYELOG-RT

Facility

$942.00

Service Code	HCPCS 50690RT
Hospital Charge Code	2691705
Hospital Revenue Code	761
Min. Negotiated Rate	$141.30
Max. Negotiated Rate	$141.30
Rate for Payer: Qualcare PPO/HMO/WC	$141.30

IR-INJ FOR URETOPYELOG-RT

Facility

$942.00

Service Code	HCPCS 50690RT
Hospital Charge Code	7411981
Hospital Revenue Code	761
Min. Negotiated Rate	$141.30
Max. Negotiated Rate	$141.30
Rate for Payer: Qualcare PPO/HMO/WC	$141.30

IR-INJ FOR URETOPYELOG-RT

Facility

$942.00

Service Code	HCPCS 50690RT
Hospital Charge Code	7411981
Hospital Revenue Code	761
Min. Negotiated Rate	$122.46
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: Aetna Medicare Advantage	$282.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$240.21
Rate for Payer: Cigna Commercial	$471.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$122.46
Rate for Payer: Oxford Commercial	$471.00
Rate for Payer: Qualcare PPO/HMO/WC	$141.30
Rate for Payer: UnitedHealthcare Commercial	$471.00

IR-INJ FOR URETOPYELOG-RT

Facility

$942.00

Service Code	HCPCS 50690RT
Hospital Charge Code	2691705
Hospital Revenue Code	761
Min. Negotiated Rate	$122.46
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: Aetna Medicare Advantage	$282.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$240.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$240.21
Rate for Payer: Cigna Commercial	$471.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$122.46
Rate for Payer: Oxford Commercial	$471.00
Rate for Payer: Qualcare PPO/HMO/WC	$141.30
Rate for Payer: UnitedHealthcare Commercial	$471.00

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	2004455
Hospital Revenue Code	361
Min. Negotiated Rate	$33.42
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$124.33
Rate for Payer: Aetna Medicare Advantage	$124.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$105.68
Rate for Payer: Cigna Commercial	$33.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.88
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$62.17
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	411020501
Hospital Revenue Code	361
Min. Negotiated Rate	$33.42
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$124.33
Rate for Payer: Aetna Medicare Advantage	$124.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$105.68
Rate for Payer: Cigna Commercial	$33.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.88
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$62.17
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	7411343
Hospital Revenue Code	361
Min. Negotiated Rate	$62.17
Max. Negotiated Rate	$62.17
Rate for Payer: Qualcare PPO/HMO/WC	$62.17

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	366820501
Hospital Revenue Code	361
Min. Negotiated Rate	$33.42
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$124.33
Rate for Payer: Aetna Medicare Advantage	$124.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$105.68
Rate for Payer: Cigna Commercial	$33.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.88
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$62.17
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	411020501
Hospital Revenue Code	361
Min. Negotiated Rate	$62.17
Max. Negotiated Rate	$62.17
Rate for Payer: Qualcare PPO/HMO/WC	$62.17

IR INJ OF TRACT SINOGRAM DIAG

Facility

$414.45

Service Code	HCPCS 20501
Hospital Charge Code	366820501
Hospital Revenue Code	361
Min. Negotiated Rate	$62.17
Max. Negotiated Rate	$62.17
Rate for Payer: Qualcare PPO/HMO/WC	$62.17

Know your out-of-pocket cost for care.

All Charges