Heights University Hospital

All Charges

Charge

Type

Setting

Price

MAMMAPL,W PROSTHETIC LT

Facility

$89,485.25

Service Code	HCPCS 19325
Hospital Charge Code	16000496
Hospital Revenue Code	360
Min. Negotiated Rate	$13,422.79
Max. Negotiated Rate	$13,422.79
Rate for Payer: Qualcare PPO/HMO/WC	$13,422.79

MAMMAPL,W PROSTHETIC LT

Facility

$89,485.25

Service Code	HCPCS 19325
Hospital Charge Code	16000496
Hospital Revenue Code	360
Min. Negotiated Rate	$1,864.00
Max. Negotiated Rate	$26,845.58
Rate for Payer: Aetna Commercial	$26,845.58
Rate for Payer: Aetna Medicare Advantage	$26,845.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22,818.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22,818.74
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	$22,818.74
Rate for Payer: Cigna Commercial	$19,464.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11,633.08
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$13,422.79
Rate for Payer: UnitedHealthcare Commercial	$9,851.00

MAMMO BOTH/ADD VIEW-KOMEN

Facility

$50.00

Service Code	HCPCS 77055
Hospital Charge Code	94061185
Hospital Revenue Code	401
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$15.00
Rate for Payer: Aetna Medicare Advantage	$15.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.75
Rate for Payer: Cigna Commercial	$25.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.50
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$7.50
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO BOTH/ADD VIEW-KOMEN

Facility

$50.00

Service Code	HCPCS 77055
Hospital Charge Code	94061185
Hospital Revenue Code	401
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.50

MAMMO BOTH BRSTS-GL

Facility

$643.60

Service Code	HCPCS 77056
Hospital Charge Code	85000140
Hospital Revenue Code	401
Min. Negotiated Rate	$83.67
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$193.08
Rate for Payer: Aetna Medicare Advantage	$193.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$164.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$164.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$164.12
Rate for Payer: Cigna Commercial	$321.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$83.67
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$96.54
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO BOTH BRSTS-GL

Facility

$643.60

Service Code	HCPCS 77056
Hospital Charge Code	85000140
Hospital Revenue Code	401
Min. Negotiated Rate	$96.54
Max. Negotiated Rate	$96.54
Rate for Payer: Qualcare PPO/HMO/WC	$96.54

MAMMO BOTH BRSTS-PC

Facility

$230.10

Service Code	HCPCS 7705626
Hospital Charge Code	85000150
Hospital Revenue Code	401
Min. Negotiated Rate	$34.52
Max. Negotiated Rate	$34.52
Rate for Payer: Qualcare PPO/HMO/WC	$34.52

MAMMO BOTH BRSTS-PC

Facility

$230.10

Service Code	HCPCS 7705626
Hospital Charge Code	85000150
Hospital Revenue Code	401
Min. Negotiated Rate	$29.91
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$69.03
Rate for Payer: Aetna Medicare Advantage	$69.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.68
Rate for Payer: Cigna Commercial	$115.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.91
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$34.52
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO BOTH BRSTS-TC

Facility

$413.55

Service Code	HCPCS 77056TC
Hospital Charge Code	85000145
Hospital Revenue Code	401
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$124.06
Rate for Payer: Aetna Medicare Advantage	$124.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$105.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$105.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$105.46
Rate for Payer: Cigna Commercial	$206.78
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.76
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$62.03
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO BOTH BRSTS-TC

Facility

$413.55

Service Code	HCPCS 77056TC
Hospital Charge Code	85000145
Hospital Revenue Code	401
Min. Negotiated Rate	$62.03
Max. Negotiated Rate	$62.03
Rate for Payer: Qualcare PPO/HMO/WC	$62.03

MAMMOGRAPHY-BILAT

Facility

$396.00

Service Code	HCPCS 77056
Hospital Charge Code	94061187
Hospital Revenue Code	401
Min. Negotiated Rate	$51.48
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: Aetna Medicare Advantage	$118.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$100.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$100.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$100.98
Rate for Payer: Cigna Commercial	$198.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$51.48
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$59.40
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMOGRAPHY-BILAT

Facility

$396.00

Service Code	HCPCS 77056
Hospital Charge Code	94061187
Hospital Revenue Code	401
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$59.40
Rate for Payer: Qualcare PPO/HMO/WC	$59.40

MAMMOGRAPHY-LT

Facility

$208.00

Service Code	HCPCS 77055LT
Hospital Charge Code	94061437
Hospital Revenue Code	401
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$31.20
Rate for Payer: Qualcare PPO/HMO/WC	$31.20

MAMMOGRAPHY-LT

Facility

$208.00

Service Code	HCPCS 77055LT
Hospital Charge Code	94061437
Hospital Revenue Code	401
Min. Negotiated Rate	$27.04
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$62.40
Rate for Payer: Aetna Medicare Advantage	$62.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.04
Rate for Payer: Cigna Commercial	$104.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.04
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$31.20
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMOGRAPHY-RT

Facility

$208.00

Service Code	HCPCS 77055RT
Hospital Charge Code	94061439
Hospital Revenue Code	401
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$31.20
Rate for Payer: Qualcare PPO/HMO/WC	$31.20

MAMMOGRAPHY-RT

Facility

$208.00

Service Code	HCPCS 77055RT
Hospital Charge Code	94061439
Hospital Revenue Code	401
Min. Negotiated Rate	$27.04
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$62.40
Rate for Payer: Aetna Medicare Advantage	$62.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$53.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$53.04
Rate for Payer: Cigna Commercial	$104.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$27.04
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$31.20
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMOL OINTMENT/15GM

Facility

$43.00

Hospital Charge Code	60634300
Hospital Revenue Code	250
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$6.45
Rate for Payer: Qualcare PPO/HMO/WC	$6.45

MAMMOL OINTMENT/15GM

Facility

$43.00

Hospital Charge Code	60634300
Hospital Revenue Code	250
Min. Negotiated Rate	$5.59
Max. Negotiated Rate	$21.50
Rate for Payer: Aetna Commercial	$12.90
Rate for Payer: Aetna Medicare Advantage	$12.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.96
Rate for Payer: Cigna Commercial	$21.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.59
Rate for Payer: Oxford Commercial	$21.50
Rate for Payer: Qualcare PPO/HMO/WC	$6.45
Rate for Payer: UnitedHealthcare Commercial	$21.50

MAMMO NDLE/WIRE LOC BRST RT

Facility

$996.00

Service Code	HCPCS 19281
Hospital Charge Code	2008040
Hospital Revenue Code	361
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$149.40
Rate for Payer: Qualcare PPO/HMO/WC	$149.40

MAMMO NDLE/WIRE LOC BRST RT

Facility

$996.00

Service Code	HCPCS 19281
Hospital Charge Code	2008040
Hospital Revenue Code	361
Min. Negotiated Rate	$129.48
Max. Negotiated Rate	$3,933.12
Rate for Payer: Aetna Commercial	$298.80
Rate for Payer: Aetna Medicare Advantage	$298.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$253.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$253.98
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	$253.98
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$129.48
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$149.40
Rate for Payer: UnitedHealthcare Commercial	$3,687.00

MAMMO ONE BRST-GL

Facility

$502.65

Service Code	HCPCS 77055
Hospital Charge Code	85000125
Hospital Revenue Code	401
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$75.40
Rate for Payer: Qualcare PPO/HMO/WC	$75.40

MAMMO ONE BRST-GL

Facility

$502.65

Service Code	HCPCS 77055
Hospital Charge Code	85000125
Hospital Revenue Code	401
Min. Negotiated Rate	$65.34
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$150.79
Rate for Payer: Aetna Medicare Advantage	$150.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.18
Rate for Payer: Cigna Commercial	$251.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.34
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$75.40
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO ONE BRST-PC

Facility

$186.00

Service Code	HCPCS 7705526
Hospital Charge Code	85000135
Hospital Revenue Code	401
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: Aetna Medicare Advantage	$55.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47.43
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.18
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

MAMMO ONE BRST-PC

Facility

$186.00

Service Code	HCPCS 7705526
Hospital Charge Code	85000135
Hospital Revenue Code	401
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

MAMMO ONE BRST-TC

Facility

$316.65

Service Code	HCPCS 77055TC
Hospital Charge Code	85000130
Hospital Revenue Code	401
Min. Negotiated Rate	$41.16
Max. Negotiated Rate	$1,240.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare Advantage	$95.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$80.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$80.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$80.75
Rate for Payer: Cigna Commercial	$158.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$41.16
Rate for Payer: Oxford Commercial	$1,092.00
Rate for Payer: Qualcare PPO/HMO/WC	$47.50
Rate for Payer: UnitedHealthcare Commercial	$1,240.00

Know your out-of-pocket cost for care.

All Charges