Heights University Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE/PRILOCAINE 2.5 5MG

Facility

$57.08

Service Code	NDC 168035730
Hospital Charge Code	606351010
Hospital Revenue Code	250
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$8.56
Rate for Payer: Qualcare PPO/HMO/WC	$8.56

LIDOCAINE/PRILOCAINE 2.5 5MG

Facility

$57.08

Service Code	NDC 168035730
Hospital Charge Code	606351010
Hospital Revenue Code	250
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$28.54
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: Aetna Medicare Advantage	$17.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.56
Rate for Payer: Cigna Commercial	$28.54
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.42
Rate for Payer: Oxford Commercial	$28.54
Rate for Payer: Qualcare PPO/HMO/WC	$8.56
Rate for Payer: UnitedHealthcare Commercial	$28.54

LIDOCAINE PRILOCAINE CRM 5GM

Facility

$57.60

Hospital Charge Code	60628419
Hospital Revenue Code	250
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna Commercial	$17.28
Rate for Payer: Aetna Medicare Advantage	$17.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.69
Rate for Payer: Cigna Commercial	$28.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.49
Rate for Payer: Oxford Commercial	$28.80
Rate for Payer: Qualcare PPO/HMO/WC	$8.64
Rate for Payer: UnitedHealthcare Commercial	$28.80

LIDOCAINE PRILOCAINE CRM 5GM

Facility

$57.60

Hospital Charge Code	60628419
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$8.64
Rate for Payer: Qualcare PPO/HMO/WC	$8.64

LIDOCAINE RUGBY PATCH 4%

Facility

$187.53

Service Code	NDC 536120207
Hospital Charge Code	606390564
Hospital Revenue Code	250
Min. Negotiated Rate	$28.13
Max. Negotiated Rate	$28.13
Rate for Payer: Qualcare PPO/HMO/WC	$28.13

LIDOCAINE RUGBY PATCH 4%

Facility

$187.53

Service Code	NDC 536120207
Hospital Charge Code	606390564
Hospital Revenue Code	250
Min. Negotiated Rate	$24.38
Max. Negotiated Rate	$93.77
Rate for Payer: Aetna Commercial	$56.26
Rate for Payer: Aetna Medicare Advantage	$56.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.82
Rate for Payer: Cigna Commercial	$93.77
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.38
Rate for Payer: Oxford Commercial	$93.77
Rate for Payer: Qualcare PPO/HMO/WC	$28.13
Rate for Payer: UnitedHealthcare Commercial	$93.77

LIDOCAINE (SERUM)

Facility

$128.00

Service Code	HCPCS 80176
Hospital Charge Code	3007572
Hospital Revenue Code	301
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$47.60
Rate for Payer: Aetna Medicare Advantage	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$33.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.82
Rate for Payer: Cigna Commercial	$14.69
Rate for Payer: Cigna Medicare Advantage	$7.34
Rate for Payer: Clover Medicare Advantage	$13.96
Rate for Payer: EmblemHealth Commercial	$44.07
Rate for Payer: Humana Medicare Advantage	$15.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.64
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.20
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.69
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$15.57
Rate for Payer: Wellcare Medicare Advantage	$14.69

LIDOCAINE (SERUM)

Facility

$128.00

Service Code	HCPCS 80176
Hospital Charge Code	3007572
Hospital Revenue Code	301
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$19.20
Rate for Payer: Qualcare PPO/HMO/WC	$19.20

LIDOCAINE SYR 100MG/5ML

Facility

$24.59

Service Code	HCPCS J2003
Hospital Charge Code	60627569
Hospital Revenue Code	636
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna Commercial	$7.38
Rate for Payer: Aetna Medicare Advantage	$7.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.27
Rate for Payer: Cigna Commercial	$12.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.95
Rate for Payer: Qualcare PPO/HMO/WC	$3.69

LIDOCAINE SYR 100MG/5ML

Facility

$24.59

Service Code	HCPCS J2003
Hospital Charge Code	60627569
Hospital Revenue Code	636
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$5.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.95
Rate for Payer: Qualcare PPO/HMO/WC	$3.69

LIDOCAINE TOP 2% 10ML JELLY

Facility

$11.26

Service Code	NDC 76329301305
Hospital Charge Code	6003271
Hospital Revenue Code	250
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.69
Rate for Payer: Qualcare PPO/HMO/WC	$1.69

LIDOCAINE TOP 2% 10ML JELLY

Facility

$11.26

Service Code	NDC 76329301305
Hospital Charge Code	6003271
Hospital Revenue Code	250
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$5.63
Rate for Payer: Aetna Commercial	$3.38
Rate for Payer: Aetna Medicare Advantage	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.87
Rate for Payer: Cigna Commercial	$5.63
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.46
Rate for Payer: Oxford Commercial	$5.63
Rate for Payer: Qualcare PPO/HMO/WC	$1.69
Rate for Payer: UnitedHealthcare Commercial	$5.63

LIDOCAINE TOP 4% 50ML

Facility

$68.00

Service Code	HCPCS J2000
Hospital Charge Code	6006738
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Aetna Medicare Advantage	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.34
Rate for Payer: Cigna Commercial	$34.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.84
Rate for Payer: Oxford Commercial	$34.00
Rate for Payer: Qualcare PPO/HMO/WC	$10.20
Rate for Payer: UnitedHealthcare Commercial	$34.00

LIDOCAINE TOP 4% 50ML

Facility

$68.00

Service Code	HCPCS J2000
Hospital Charge Code	6006738
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$10.20
Rate for Payer: Qualcare PPO/HMO/WC	$10.20

LIDOCAINE UNPRES INJ 1.5%

Facility

$30.69

Service Code	NDC 409477601
Hospital Charge Code	6003297
Hospital Revenue Code	250
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$15.35
Rate for Payer: Aetna Commercial	$9.21
Rate for Payer: Aetna Medicare Advantage	$9.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.83
Rate for Payer: Cigna Commercial	$15.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.99
Rate for Payer: Oxford Commercial	$15.35
Rate for Payer: Qualcare PPO/HMO/WC	$4.60
Rate for Payer: UnitedHealthcare Commercial	$15.35

LIDOCAINE UNPRES INJ 1.5%

Facility

$30.69

Service Code	NDC 409477601
Hospital Charge Code	6003297
Hospital Revenue Code	250
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$4.60
Rate for Payer: Qualcare PPO/HMO/WC	$4.60

LIDOCAINE UNPRES INJ 2%

Facility

$21.15

Hospital Charge Code	6003305
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$10.57
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Aetna Medicare Advantage	$6.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.39
Rate for Payer: Cigna Commercial	$10.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.75
Rate for Payer: Oxford Commercial	$10.57
Rate for Payer: Qualcare PPO/HMO/WC	$3.17
Rate for Payer: UnitedHealthcare Commercial	$10.57

LIDOCAINE UNPRES INJ 2%

Facility

$21.15

Hospital Charge Code	6003305
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.17
Rate for Payer: Qualcare PPO/HMO/WC	$3.17

LIDOCAINE VISC 2% 100ML

Facility

$88.44

Service Code	NDC 54350049
Hospital Charge Code	60628414
Hospital Revenue Code	250
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$13.27
Rate for Payer: Qualcare PPO/HMO/WC	$13.27

LIDOCAINE VISC 2% 100ML

Facility

$88.44

Service Code	NDC 54350049
Hospital Charge Code	60628414
Hospital Revenue Code	250
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$44.22
Rate for Payer: Aetna Commercial	$26.53
Rate for Payer: Aetna Medicare Advantage	$26.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.55
Rate for Payer: Cigna Commercial	$44.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.50
Rate for Payer: Oxford Commercial	$44.22
Rate for Payer: Qualcare PPO/HMO/WC	$13.27
Rate for Payer: UnitedHealthcare Commercial	$44.22

LIDOCAINE VISC 2% 30ML

Facility

$6.37

Service Code	NDC 63739069457
Hospital Charge Code	60628415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$3.19
Rate for Payer: Aetna Commercial	$1.91
Rate for Payer: Aetna Medicare Advantage	$1.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.62
Rate for Payer: Cigna Commercial	$3.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.83
Rate for Payer: Oxford Commercial	$3.19
Rate for Payer: Qualcare PPO/HMO/WC	$0.96
Rate for Payer: UnitedHealthcare Commercial	$3.19

LIDOCAINE VISC 2% 30ML

Facility

$6.37

Service Code	NDC 63739069457
Hospital Charge Code	60628415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$0.96
Rate for Payer: Qualcare PPO/HMO/WC	$0.96

LIDOCAINE VISCOUS 2%/100M

Facility

$15.00

Hospital Charge Code	60633305
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$4.50
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.95
Rate for Payer: Oxford Commercial	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$7.50

LIDOCAINE VISCOUS 2%/100M

Facility

$15.00

Hospital Charge Code	60633305
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

LIDOCAINE VL 1% 30ML

Facility

$4.00

Hospital Charge Code	6012728
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

Know your out-of-pocket cost for care.

All Charges