Heights University Hospital

All Charges

Charge

Type

Setting

Price

LORAZEPAM 4MG/ML SINGLE DOES

Facility

$19.30

Service Code	NDC 641600325
Hospital Charge Code	606390581
Hospital Revenue Code	250
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$9.65
Rate for Payer: Aetna Commercial	$5.79
Rate for Payer: Aetna Medicare Advantage	$5.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.92
Rate for Payer: Cigna Commercial	$9.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.51
Rate for Payer: Oxford Commercial	$9.65
Rate for Payer: Qualcare PPO/HMO/WC	$2.90
Rate for Payer: UnitedHealthcare Commercial	$9.65

LORAZEPAM 4MG/ML SINGLE DOES

Facility

$19.30

Service Code	NDC 641600325
Hospital Charge Code	606390581
Hospital Revenue Code	250
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$2.90
Rate for Payer: Qualcare PPO/HMO/WC	$2.90

LORAZEPAM (ATIVAN)

Facility

$324.00

Service Code	HCPCS 80346
Hospital Charge Code	38472462
Hospital Revenue Code	301
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Qualcare PPO/HMO/WC	$48.60

LORAZEPAM (ATIVAN)

Facility

$324.00

Service Code	HCPCS 80346
Hospital Charge Code	38472462
Hospital Revenue Code	301
Min. Negotiated Rate	$42.12
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna Commercial	$97.20
Rate for Payer: Aetna Medicare Advantage	$97.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$82.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$82.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$82.62
Rate for Payer: Cigna Commercial	$162.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.12
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$48.60
Rate for Payer: UnitedHealthcare Commercial	$114.00

LORAZEPAM (ATIVAN)

Facility

$190.45

Service Code	HCPCS 80300
Hospital Charge Code	3000301
Hospital Revenue Code	301
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$28.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.57

LORAZEPAM (ATIVAN)

Facility

$190.45

Service Code	HCPCS 80300
Hospital Charge Code	3000301
Hospital Revenue Code	301
Min. Negotiated Rate	$24.76
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$57.13
Rate for Payer: Aetna Medicare Advantage	$57.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.56
Rate for Payer: Cigna Commercial	$95.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.76
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$28.57
Rate for Payer: UnitedHealthcare Commercial	$114.00

LORAZEPAM (ATIVAN) 2MG TAB

Facility

$8.84

Service Code	NDC 51079038720
Hospital Charge Code	60630183
Hospital Revenue Code	250
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$4.42
Rate for Payer: Aetna Commercial	$2.65
Rate for Payer: Aetna Medicare Advantage	$2.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.25
Rate for Payer: Cigna Commercial	$4.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.15
Rate for Payer: Oxford Commercial	$4.42
Rate for Payer: Qualcare PPO/HMO/WC	$1.33
Rate for Payer: UnitedHealthcare Commercial	$4.42

LORAZEPAM (ATIVAN) 2MG TAB

Facility

$8.84

Service Code	NDC 51079038720
Hospital Charge Code	60630183
Hospital Revenue Code	250
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.33
Rate for Payer: Qualcare PPO/HMO/WC	$1.33

LORAZEPAM INJ 2MG/ML

Facility

$70.40

Hospital Charge Code	6010508
Hospital Revenue Code	250
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$10.56
Rate for Payer: Qualcare PPO/HMO/WC	$10.56

LORAZEPAM INJ 2MG/ML

Facility

$70.40

Hospital Charge Code	6010508
Hospital Revenue Code	250
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$35.20
Rate for Payer: Aetna Commercial	$21.12
Rate for Payer: Aetna Medicare Advantage	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.95
Rate for Payer: Cigna Commercial	$35.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.15
Rate for Payer: Oxford Commercial	$35.20
Rate for Payer: Qualcare PPO/HMO/WC	$10.56
Rate for Payer: UnitedHealthcare Commercial	$35.20

LORAZEPAM INJ 40MG/10ML

Facility

$74.37

Service Code	HCPCS J2060
Hospital Charge Code	60627848
Hospital Revenue Code	636
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$18.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.16

LORAZEPAM INJ 40MG/10ML

Facility

$74.37

Service Code	HCPCS J2060
Hospital Charge Code	60627848
Hospital Revenue Code	636
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$22.31
Rate for Payer: Aetna Medicare Advantage	$22.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.96
Rate for Payer: Cigna Commercial	$1.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.00
Rate for Payer: Qualcare PPO/HMO/WC	$11.16

LORDOTIC PEEK 12X12X10

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658053
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X10

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658053
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$4,050.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X5

Facility

$13,500.00

Hospital Charge Code	270658066
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$4,050.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X5

Facility

$13,500.00

Hospital Charge Code	270658066
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X6

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658065
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$4,050.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X6

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270658065
Hospital Revenue Code	278
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$3,267.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,700.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,267.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12x12x6MM

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270667220
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$4,500.00
Rate for Payer: Aetna Commercial	$2,700.00
Rate for Payer: Aetna Medicare Advantage	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,295.00
Rate for Payer: Cigna Commercial	$4,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

LORDOTIC PEEK 12x12x6MM

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270667220
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,178.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

LORDOTIC PEEK 12X12X8

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270657660
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,178.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

LORDOTIC PEEK 12X12X8

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270657660
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$4,500.00
Rate for Payer: Aetna Commercial	$2,700.00
Rate for Payer: Aetna Medicare Advantage	$2,700.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,295.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,295.00
Rate for Payer: Cigna Commercial	$4,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

LORDOTIC PEEK 12X12X9

Facility

$13,500.00

Hospital Charge Code	270657664
Hospital Revenue Code	270
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

LORDOTIC PEEK 12X12X9

Facility

$13,500.00

Hospital Charge Code	270657664
Hospital Revenue Code	270
Min. Negotiated Rate	$1,755.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna Commercial	$4,050.00
Rate for Payer: Aetna Medicare Advantage	$4,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,442.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,442.50
Rate for Payer: Cigna Commercial	$6,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,755.00
Rate for Payer: Oxford Commercial	$6,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,750.00

LORDOTIC PEEK WASTE 12X12X7

Facility

$9,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270658068
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,178.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,178.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,350.00

Know your out-of-pocket cost for care.

All Charges