Heights University Hospital

All Charges

Charge

Type

Setting

Price

LENS ADD RESTORE 15.00 +3.00

Facility

$4,345.00

Service Code	HCPCS V2788
Hospital Charge Code	270685027
Hospital Revenue Code	276
Min. Negotiated Rate	$651.75
Max. Negotiated Rate	$2,172.50
Rate for Payer: Aetna Commercial	$1,303.50
Rate for Payer: Aetna Medicare Advantage	$1,303.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,107.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,107.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,107.97
Rate for Payer: Cigna Commercial	$2,172.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,051.49
Rate for Payer: Qualcare PPO/HMO/WC	$651.75

LENS ADD RESTORE 15.00 +3.00

Facility

$4,345.00

Service Code	HCPCS V2788
Hospital Charge Code	270685027
Hospital Revenue Code	276
Min. Negotiated Rate	$651.75
Max. Negotiated Rate	$1,051.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,051.49
Rate for Payer: Qualcare PPO/HMO/WC	$651.75

LENS ADD RESTORE 22.00

Facility

$4,475.00

Hospital Charge Code	270677204
Hospital Revenue Code	276
Min. Negotiated Rate	$671.25
Max. Negotiated Rate	$2,237.50
Rate for Payer: Aetna Commercial	$1,342.50
Rate for Payer: Aetna Medicare Advantage	$1,342.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,141.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,141.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,141.12
Rate for Payer: Cigna Commercial	$2,237.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,082.95
Rate for Payer: Qualcare PPO/HMO/WC	$671.25

LENS ADD RESTORE 22.00

Facility

$4,475.00

Hospital Charge Code	270677204
Hospital Revenue Code	276
Min. Negotiated Rate	$671.25
Max. Negotiated Rate	$1,082.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,082.95
Rate for Payer: Qualcare PPO/HMO/WC	$671.25

LENS ADD RESTORE 22.50

Facility

$4,475.00

Service Code	HCPCS V2788
Hospital Charge Code	270677205
Hospital Revenue Code	276
Min. Negotiated Rate	$671.25
Max. Negotiated Rate	$2,237.50
Rate for Payer: Aetna Commercial	$1,342.50
Rate for Payer: Aetna Medicare Advantage	$1,342.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,141.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,141.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,141.12
Rate for Payer: Cigna Commercial	$2,237.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,082.95
Rate for Payer: Qualcare PPO/HMO/WC	$671.25

LENS ADD RESTORE 22.50

Facility

$4,475.00

Service Code	HCPCS V2788
Hospital Charge Code	270677205
Hospital Revenue Code	276
Min. Negotiated Rate	$671.25
Max. Negotiated Rate	$1,082.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,082.95
Rate for Payer: Qualcare PPO/HMO/WC	$671.25

LENS CHIROFLEX C11UB 10.0

Facility

$590.25

Hospital Charge Code	270617658
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 10.0

Facility

$590.25

Hospital Charge Code	270617658
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 10.5

Facility

$590.25

Hospital Charge Code	270634187
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 10.5

Facility

$590.25

Hospital Charge Code	270634187
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 11.0

Facility

$590.25

Hospital Charge Code	270623251
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 11.0

Facility

$590.25

Hospital Charge Code	270623251
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 12.0

Facility

$744.00

Hospital Charge Code	270619577
Hospital Revenue Code	276
Min. Negotiated Rate	$111.60
Max. Negotiated Rate	$180.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$180.05
Rate for Payer: Qualcare PPO/HMO/WC	$111.60

LENS CHIROFLEX C11UB 12.0

Facility

$744.00

Hospital Charge Code	270619577
Hospital Revenue Code	276
Min. Negotiated Rate	$111.60
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$223.20
Rate for Payer: Aetna Medicare Advantage	$223.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$189.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$189.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$189.72
Rate for Payer: Cigna Commercial	$372.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$180.05
Rate for Payer: Qualcare PPO/HMO/WC	$111.60

LENS CHIROFLEX C11UB 13.5

Facility

$590.45

Hospital Charge Code	270619110
Hospital Revenue Code	276
Min. Negotiated Rate	$88.57
Max. Negotiated Rate	$295.23
Rate for Payer: Aetna Commercial	$177.13
Rate for Payer: Aetna Medicare Advantage	$177.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.56
Rate for Payer: Cigna Commercial	$295.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.89
Rate for Payer: Qualcare PPO/HMO/WC	$88.57

LENS CHIROFLEX C11UB 13.5

Facility

$590.45

Hospital Charge Code	270619110
Hospital Revenue Code	276
Min. Negotiated Rate	$88.57
Max. Negotiated Rate	$142.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.89
Rate for Payer: Qualcare PPO/HMO/WC	$88.57

LENS CHIROFLEX C11UB 28.5

Facility

$590.25

Hospital Charge Code	270626599
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 28.5

Facility

$590.25

Hospital Charge Code	270626599
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.0

Facility

$590.25

Hospital Charge Code	270633585
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.0

Facility

$590.25

Hospital Charge Code	270633585
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.5

Facility

$590.25

Hospital Charge Code	270631195
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.5

Facility

$590.25

Hospital Charge Code	270631195
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.5

Facility

$590.25

Hospital Charge Code	27063115
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$295.12
Rate for Payer: Aetna Commercial	$177.07
Rate for Payer: Aetna Medicare Advantage	$177.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.51
Rate for Payer: Cigna Commercial	$295.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS CHIROFLEX C11UB 29.5

Facility

$590.25

Hospital Charge Code	27063115
Hospital Revenue Code	276
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$142.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$142.84
Rate for Payer: Qualcare PPO/HMO/WC	$88.54

LENS FOLDABLE AA4204VL 20.5

Facility

$550.00

Hospital Charge Code	270624211
Hospital Revenue Code	276
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$165.00
Rate for Payer: Aetna Medicare Advantage	$165.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$140.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$140.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$140.25
Rate for Payer: Cigna Commercial	$275.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$133.10
Rate for Payer: Qualcare PPO/HMO/WC	$82.50

Know your out-of-pocket cost for care.

All Charges