Heights University Hospital

All Charges

Charge

Type

Setting

Price

NM IN-111 PENTETREOTIDE DOSE U

Facility

$11,533.70

Service Code	HCPCS A9572
Hospital Charge Code	4501021
Hospital Revenue Code	343
Min. Negotiated Rate	$1,730.06
Max. Negotiated Rate	$1,730.06
Rate for Payer: Qualcare PPO/HMO/WC	$1,730.06

NM IN-111 PENTETREOTIDE DOSE U

Facility

$11,533.70

Service Code	HCPCS A9572
Hospital Charge Code	4501021
Hospital Revenue Code	343
Min. Negotiated Rate	$1,432.12
Max. Negotiated Rate	$3,460.11
Rate for Payer: Aetna Commercial	$3,460.11
Rate for Payer: Aetna Medicare Advantage	$3,460.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,941.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,941.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,432.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,941.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,499.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,730.06

NM IN-111 ZEVALIN DOSE UP TO 5

Facility

$11,188.00

Hospital Charge Code	4500297
Hospital Revenue Code	343
Min. Negotiated Rate	$1,678.20
Max. Negotiated Rate	$1,678.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,678.20

NM IN-111 ZEVALIN DOSE UP TO 5

Facility

$11,188.00

Hospital Charge Code	4500297
Hospital Revenue Code	343
Min. Negotiated Rate	$1,454.44
Max. Negotiated Rate	$5,594.00
Rate for Payer: Aetna Commercial	$3,356.40
Rate for Payer: Aetna Medicare Advantage	$3,356.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,852.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,852.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,852.94
Rate for Payer: Cigna Commercial	$5,594.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,454.44
Rate for Payer: Qualcare PPO/HMO/WC	$1,678.20

NM INDIUM DTPA/0.5 MCI

Facility

$3,503.00

Hospital Charge Code	4508055
Hospital Revenue Code	343
Min. Negotiated Rate	$455.39
Max. Negotiated Rate	$1,751.50
Rate for Payer: Aetna Commercial	$1,050.90
Rate for Payer: Aetna Medicare Advantage	$1,050.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$893.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$893.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$893.26
Rate for Payer: Cigna Commercial	$1,751.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$455.39
Rate for Payer: Qualcare PPO/HMO/WC	$525.45

NM INDIUM DTPA/0.5 MCI

Facility

$3,503.00

Hospital Charge Code	4508055
Hospital Revenue Code	343
Min. Negotiated Rate	$525.45
Max. Negotiated Rate	$525.45
Rate for Payer: Qualcare PPO/HMO/WC	$525.45

NM INDIUM III OXYQUIN / 5mCi

Facility

$1,306.45

Hospital Charge Code	4500815
Hospital Revenue Code	343
Min. Negotiated Rate	$169.84
Max. Negotiated Rate	$653.23
Rate for Payer: Aetna Commercial	$391.94
Rate for Payer: Aetna Medicare Advantage	$391.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$333.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$333.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$333.14
Rate for Payer: Cigna Commercial	$653.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$169.84
Rate for Payer: Qualcare PPO/HMO/WC	$195.97

NM INDIUM III OXYQUIN / 5mCi

Facility

$1,306.45

Hospital Charge Code	4500815
Hospital Revenue Code	343
Min. Negotiated Rate	$195.97
Max. Negotiated Rate	$195.97
Rate for Payer: Qualcare PPO/HMO/WC	$195.97

NM INDIUM III PENT PER 1.5mCi

Facility

$1,972.85

Service Code	HCPCS A9507
Hospital Charge Code	4500296
Hospital Revenue Code	343
Min. Negotiated Rate	$295.93
Max. Negotiated Rate	$295.93
Rate for Payer: Qualcare PPO/HMO/WC	$295.93

NM INDIUM III PENT PER 1.5mCi

Facility

$1,972.85

Service Code	HCPCS A9507
Hospital Charge Code	4500296
Hospital Revenue Code	343
Min. Negotiated Rate	$256.47
Max. Negotiated Rate	$5,971.13
Rate for Payer: Aetna Commercial	$591.86
Rate for Payer: Aetna Medicare Advantage	$591.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$503.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$503.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,971.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$503.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$256.47
Rate for Payer: Qualcare PPO/HMO/WC	$295.93

NM INDIUM II,UP TO 6 MCI

Facility

$3,503.00

Hospital Charge Code	4508065
Hospital Revenue Code	343
Min. Negotiated Rate	$455.39
Max. Negotiated Rate	$1,751.50
Rate for Payer: Aetna Commercial	$1,050.90
Rate for Payer: Aetna Medicare Advantage	$1,050.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$893.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$893.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$893.26
Rate for Payer: Cigna Commercial	$1,751.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$455.39
Rate for Payer: Qualcare PPO/HMO/WC	$525.45

NM INDIUM II,UP TO 6 MCI

Facility

$3,503.00

Hospital Charge Code	4508065
Hospital Revenue Code	343
Min. Negotiated Rate	$525.45
Max. Negotiated Rate	$525.45
Rate for Payer: Qualcare PPO/HMO/WC	$525.45

NM INJECTION KIT

Facility

$134.45

Hospital Charge Code	4500865
Hospital Revenue Code	272
Min. Negotiated Rate	$17.48
Max. Negotiated Rate	$67.22
Rate for Payer: Aetna Commercial	$40.34
Rate for Payer: Aetna Medicare Advantage	$40.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.28
Rate for Payer: Cigna Commercial	$67.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.48
Rate for Payer: Oxford Commercial	$67.22
Rate for Payer: Qualcare PPO/HMO/WC	$20.17
Rate for Payer: UnitedHealthcare Commercial	$67.22

NM INJECTION KIT

Facility

$134.45

Hospital Charge Code	4500865
Hospital Revenue Code	272
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$20.17
Rate for Payer: Qualcare PPO/HMO/WC	$20.17

NM INJ LYMPH/SENTINEL NODE

Facility

$598.75

Service Code	HCPCS 38792
Hospital Charge Code	4500886
Hospital Revenue Code	361
Min. Negotiated Rate	$89.81
Max. Negotiated Rate	$89.81
Rate for Payer: Qualcare PPO/HMO/WC	$89.81

NM INJ LYMPH/SENTINEL NODE

Facility

$598.75

Service Code	HCPCS 38792
Hospital Charge Code	4500886
Hospital Revenue Code	361
Min. Negotiated Rate	$77.84
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$179.62
Rate for Payer: Aetna Medicare Advantage	$179.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$152.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$152.68
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	$152.68
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.84
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$89.81
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

NM IODINE 131CAP PERmCi THERAP

Facility

$382.45

Service Code	HCPCS A9517
Hospital Charge Code	4500799
Hospital Revenue Code	344
Min. Negotiated Rate	$39.27
Max. Negotiated Rate	$114.73
Rate for Payer: Aetna Commercial	$114.73
Rate for Payer: Aetna Medicare Advantage	$114.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$97.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$97.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$39.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$97.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$49.72
Rate for Payer: Qualcare PPO/HMO/WC	$57.37

NM IODINE 131CAP PERmCi THERAP

Facility

$382.45

Service Code	HCPCS A9517
Hospital Charge Code	4500799
Hospital Revenue Code	344
Min. Negotiated Rate	$57.37
Max. Negotiated Rate	$57.37
Rate for Payer: Qualcare PPO/HMO/WC	$57.37

NM IODINE 131 PER CAP 15mCi**

Facility

$156.00

Service Code	HCPCS C1188
Hospital Charge Code	4500781
Hospital Revenue Code	342
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Qualcare PPO/HMO/WC	$23.40

NM IODINE 131 PER CAP 15mCi**

Facility

$156.00

Service Code	HCPCS C1188
Hospital Charge Code	4500781
Hospital Revenue Code	342
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$3,540.00
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare Advantage	$46.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.78
Rate for Payer: Cigna Commercial	$78.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$20.28
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$23.40
Rate for Payer: UnitedHealthcare Commercial	$3,540.00

NM IODINE 131 PER CAP 20mCi

Facility

$390.00

Service Code	HCPCS C1188
Hospital Charge Code	4500773
Hospital Revenue Code	342
Min. Negotiated Rate	$50.70
Max. Negotiated Rate	$3,540.00
Rate for Payer: Aetna Commercial	$117.00
Rate for Payer: Aetna Medicare Advantage	$117.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$99.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.70
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$3,540.00

NM IODINE 131 PER CAP 20mCi

Facility

$390.00

Service Code	HCPCS C1188
Hospital Charge Code	4500773
Hospital Revenue Code	342
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

NM IODINE I-131/0.5 MCI

Facility

$1,637.00

Hospital Charge Code	4508050
Hospital Revenue Code	343
Min. Negotiated Rate	$245.55
Max. Negotiated Rate	$245.55
Rate for Payer: Qualcare PPO/HMO/WC	$245.55

NM IODINE I-131/0.5 MCI

Facility

$1,637.00

Hospital Charge Code	4508050
Hospital Revenue Code	343
Min. Negotiated Rate	$212.81
Max. Negotiated Rate	$818.50
Rate for Payer: Aetna Commercial	$491.10
Rate for Payer: Aetna Medicare Advantage	$491.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$417.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$417.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$417.44
Rate for Payer: Cigna Commercial	$818.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$212.81
Rate for Payer: Qualcare PPO/HMO/WC	$245.55

NM KIDNEY FUNCT STUDY NON-IMAG

Facility

$1,296.25

Service Code	HCPCS 78725
Hospital Charge Code	4500963
Hospital Revenue Code	341
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$3,540.00
Rate for Payer: Aetna Commercial	$388.88
Rate for Payer: Aetna Medicare Advantage	$388.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$330.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$330.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$56.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$330.54
Rate for Payer: Cigna Commercial	$952.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$168.51
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$194.44
Rate for Payer: UnitedHealthcare Commercial	$3,540.00

Know your out-of-pocket cost for care.

All Charges