Heights University Hospital

All Charges

Charge

Type

Setting

Price

MODIFIER ROAD RUNNER THE FIRM

Facility

$306.00

Service Code	HCPCS C1769
Hospital Charge Code	270660261
Hospital Revenue Code	278
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$74.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.05
Rate for Payer: Qualcare PPO/HMO/WC	$45.90

MODIFIER ROAD RUNNER THE FIRM

Facility

$306.00

Service Code	HCPCS C1769
Hospital Charge Code	270660261
Hospital Revenue Code	278
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Aetna Medicare Advantage	$91.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$78.03
Rate for Payer: Cigna Commercial	$153.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.05
Rate for Payer: Qualcare PPO/HMO/WC	$45.90

MOD POLYAXIAL HEAD

Facility

$3,125.00

Hospital Charge Code	270702840
Hospital Revenue Code	278
Min. Negotiated Rate	$468.75
Max. Negotiated Rate	$1,562.50
Rate for Payer: Aetna Commercial	$937.50
Rate for Payer: Aetna Medicare Advantage	$937.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$796.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$796.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$625.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$796.88
Rate for Payer: Cigna Commercial	$1,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$756.25
Rate for Payer: Qualcare PPO/HMO/WC	$468.75

MOD POLYAXIAL HEAD

Facility

$3,125.00

Hospital Charge Code	270702840
Hospital Revenue Code	278
Min. Negotiated Rate	$468.75
Max. Negotiated Rate	$756.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$756.25
Rate for Payer: Qualcare PPO/HMO/WC	$468.75

MOD REFORM MIS EXTENDED TABS

Facility

$6,740.00

Service Code	HCPCS C1713
Hospital Charge Code	270696621
Hospital Revenue Code	278
Min. Negotiated Rate	$1,011.00
Max. Negotiated Rate	$3,370.00
Rate for Payer: Aetna Commercial	$2,022.00
Rate for Payer: Aetna Medicare Advantage	$2,022.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,718.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,718.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,348.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,718.70
Rate for Payer: Cigna Commercial	$3,370.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,631.08
Rate for Payer: Qualcare PPO/HMO/WC	$1,011.00

MOD REFORM MIS EXTENDED TABS

Facility

$6,740.00

Service Code	HCPCS C1713
Hospital Charge Code	270696621
Hospital Revenue Code	278
Min. Negotiated Rate	$1,011.00
Max. Negotiated Rate	$1,631.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,348.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,631.08
Rate for Payer: Qualcare PPO/HMO/WC	$1,011.00

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2692143
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	321099155
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5792288
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	7412072
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5100851
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5792288
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2500267
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2692143
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	7412072
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	2500267
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	5100851
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	366899155
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	366899155
Hospital Revenue Code	370
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$252.28
Rate for Payer: Aetna Commercial	$151.37
Rate for Payer: Aetna Medicare Advantage	$151.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$128.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$128.66
Rate for Payer: Cigna Commercial	$87.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$65.59
Rate for Payer: Oxford Commercial	$252.28
Rate for Payer: Qualcare PPO/HMO/WC	$75.68
Rate for Payer: UnitedHealthcare Commercial	$252.28

MOD SED DIFF MD <5YO1ST 15MIN

Facility

$504.55

Service Code	HCPCS 99155
Hospital Charge Code	321099155
Hospital Revenue Code	370
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$75.68
Rate for Payer: Qualcare PPO/HMO/WC	$75.68

MOD SED DIFF MD >5YO1ST 15MIN

Facility

$409.70

Service Code	HCPCS 99156
Hospital Charge Code	7412073
Hospital Revenue Code	370
Min. Negotiated Rate	$61.45
Max. Negotiated Rate	$61.45
Rate for Payer: Qualcare PPO/HMO/WC	$61.45

MOD SED DIFF MD >5YO1ST 15MIN

Facility

$409.70

Service Code	HCPCS 99156
Hospital Charge Code	5100852
Hospital Revenue Code	370
Min. Negotiated Rate	$53.26
Max. Negotiated Rate	$204.85
Rate for Payer: Aetna Commercial	$122.91
Rate for Payer: Aetna Medicare Advantage	$122.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$104.47
Rate for Payer: Cigna Commercial	$76.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.26
Rate for Payer: Oxford Commercial	$204.85
Rate for Payer: Qualcare PPO/HMO/WC	$61.45
Rate for Payer: UnitedHealthcare Commercial	$204.85

MOD SED DIFF MD >5YO1ST 15MIN

Facility

$409.70

Service Code	HCPCS 99156
Hospital Charge Code	2692144
Hospital Revenue Code	370
Min. Negotiated Rate	$61.45
Max. Negotiated Rate	$61.45
Rate for Payer: Qualcare PPO/HMO/WC	$61.45

MOD SED DIFF MD >5YO1ST 15MIN

Facility

$409.70

Service Code	HCPCS 99156
Hospital Charge Code	5792289
Hospital Revenue Code	370
Min. Negotiated Rate	$53.26
Max. Negotiated Rate	$204.85
Rate for Payer: Aetna Commercial	$122.91
Rate for Payer: Aetna Medicare Advantage	$122.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$104.47
Rate for Payer: Cigna Commercial	$76.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.26
Rate for Payer: Oxford Commercial	$204.85
Rate for Payer: Qualcare PPO/HMO/WC	$61.45
Rate for Payer: UnitedHealthcare Commercial	$204.85

MOD SED DIFF MD >5YO1ST 15MIN

Facility

$409.70

Service Code	HCPCS 99156
Hospital Charge Code	321099156
Hospital Revenue Code	370
Min. Negotiated Rate	$53.26
Max. Negotiated Rate	$204.85
Rate for Payer: Aetna Commercial	$122.91
Rate for Payer: Aetna Medicare Advantage	$122.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$104.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$104.47
Rate for Payer: Cigna Commercial	$76.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$53.26
Rate for Payer: Oxford Commercial	$204.85
Rate for Payer: Qualcare PPO/HMO/WC	$61.45
Rate for Payer: UnitedHealthcare Commercial	$204.85

Know your out-of-pocket cost for care.

All Charges