Heights University Hospital

All Charges

Charge

Type

Setting

Price

PERPHENAZINE 8 MG TAB

Facility

$21.84

Service Code	HCPCS Q0175
Hospital Charge Code	60627816
Hospital Revenue Code	636
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$5.29
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.29
Rate for Payer: Qualcare PPO/HMO/WC	$3.28

PERPHENAZINE AMITRIPTL TAB2-10

Facility

$4.00

Hospital Charge Code	60627775
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB2-10

Facility

$4.00

Hospital Charge Code	60627775
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

PERPHENAZINE AMITRIPTL TAB2-25

Facility

$4.85

Hospital Charge Code	60627776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.73

PERPHENAZINE AMITRIPTL TAB2-25

Facility

$4.85

Hospital Charge Code	60627776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$1.46
Rate for Payer: Aetna Medicare Advantage	$1.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.24
Rate for Payer: Cigna Commercial	$2.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.63
Rate for Payer: Oxford Commercial	$2.42
Rate for Payer: Qualcare PPO/HMO/WC	$0.73
Rate for Payer: UnitedHealthcare Commercial	$2.42

PERPHENAZINE AMITRIPTL TAB4-10

Facility

$4.00

Hospital Charge Code	60627777
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB4-10

Facility

$4.00

Hospital Charge Code	60627777
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

PERPHENAZINE AMITRIPTL TAB4-25

Facility

$4.00

Hospital Charge Code	60627778
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE AMITRIPTL TAB4-25

Facility

$4.00

Hospital Charge Code	60627778
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

PERPHENAZINE AMITRIPTL TAB4-50

Facility

$5.65

Hospital Charge Code	60627779
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

PERPHENAZINE AMITRIPTL TAB4-50

Facility

$5.65

Hospital Charge Code	60627779
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$1.70
Rate for Payer: Aetna Medicare Advantage	$1.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.44
Rate for Payer: Cigna Commercial	$2.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.73
Rate for Payer: Oxford Commercial	$2.83
Rate for Payer: Qualcare PPO/HMO/WC	$0.85
Rate for Payer: UnitedHealthcare Commercial	$2.83

PERPHENAZINE LQ 16ML/5ML

Facility

$4.00

Hospital Charge Code	6009898
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PERPHENAZINE LQ 16ML/5ML

Facility

$4.00

Hospital Charge Code	6009898
Hospital Revenue Code	251
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

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	404634713
Hospital Revenue Code	361
Min. Negotiated Rate	$1,017.75
Max. Negotiated Rate	$1,017.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	404634713
Hospital Revenue Code	361
Min. Negotiated Rate	$118.11
Max. Negotiated Rate	$2,035.50
Rate for Payer: Aetna Commercial	$2,035.50
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
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	$1,730.17
Rate for Payer: Cigna Commercial	$118.11
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$882.05
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	321034713
Hospital Revenue Code	361
Min. Negotiated Rate	$118.11
Max. Negotiated Rate	$2,035.50
Rate for Payer: Aetna Commercial	$2,035.50
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
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	$1,730.17
Rate for Payer: Cigna Commercial	$118.11
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$882.05
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	321034713
Hospital Revenue Code	361
Min. Negotiated Rate	$1,017.75
Max. Negotiated Rate	$1,017.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	411034713
Hospital Revenue Code	360
Min. Negotiated Rate	$118.11
Max. Negotiated Rate	$2,035.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75
Rate for Payer: Aetna Commercial	$2,035.50
Rate for Payer: Aetna Medicare Advantage	$2,035.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,730.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,730.17
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	$1,730.17
Rate for Payer: Cigna Commercial	$118.11
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$882.05
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

PERQ ACCESS & CLSR FEM ART

Facility

$6,785.00

Service Code	HCPCS 34713
Hospital Charge Code	411034713
Hospital Revenue Code	360
Min. Negotiated Rate	$1,017.75
Max. Negotiated Rate	$1,017.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,017.75

PERQ ART M-THROMBECT &/NFS

Facility

$61,616.39

Service Code	HCPCS 61645
Hospital Charge Code	366861645
Hospital Revenue Code	361
Min. Negotiated Rate	$9,242.46
Max. Negotiated Rate	$9,242.46
Rate for Payer: Qualcare PPO/HMO/WC	$9,242.46

PERQ ART M-THROMBECT &/NFS

Facility

$61,616.39

Service Code	HCPCS 61645
Hospital Charge Code	411061645
Hospital Revenue Code	361
Min. Negotiated Rate	$816.16
Max. Negotiated Rate	$18,484.92
Rate for Payer: Aetna Commercial	$18,484.92
Rate for Payer: Aetna Medicare Advantage	$18,484.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,712.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,712.18
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	$15,712.18
Rate for Payer: Cigna Commercial	$816.16
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,010.13
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,242.46
Rate for Payer: UnitedHealthcare Commercial	$6,873.00

PERQ ART M-THROMBECT &/NFS

Facility

$61,616.39

Service Code	HCPCS 61645
Hospital Charge Code	366861645
Hospital Revenue Code	361
Min. Negotiated Rate	$816.16
Max. Negotiated Rate	$18,484.92
Rate for Payer: Aetna Commercial	$18,484.92
Rate for Payer: Aetna Medicare Advantage	$18,484.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,712.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,712.18
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	$15,712.18
Rate for Payer: Cigna Commercial	$816.16
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,010.13
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$9,242.46
Rate for Payer: UnitedHealthcare Commercial	$6,873.00

PERQ ART M-THROMBECT &/NFS

Facility

$61,616.39

Service Code	HCPCS 61645
Hospital Charge Code	411061645
Hospital Revenue Code	361
Min. Negotiated Rate	$9,242.46
Max. Negotiated Rate	$9,242.46
Rate for Payer: Qualcare PPO/HMO/WC	$9,242.46

PERQ CERVICOTHORACIC INJECT

Facility

$15,447.21

Service Code	HCPCS 22510
Hospital Charge Code	5701103
Hospital Revenue Code	320
Min. Negotiated Rate	$2,317.08
Max. Negotiated Rate	$2,317.08
Rate for Payer: Qualcare PPO/HMO/WC	$2,317.08

PERQ CERVICOTHORACIC INJECT

Facility

$15,447.21

Service Code	HCPCS 22510
Hospital Charge Code	5701103
Hospital Revenue Code	320
Min. Negotiated Rate	$1,191.93
Max. Negotiated Rate	$7,791.93
Rate for Payer: Aetna Commercial	$4,634.16
Rate for Payer: Aetna Medicare Advantage	$4,634.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,939.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,939.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,191.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,939.04
Rate for Payer: Cigna Commercial	$7,791.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,008.14
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,317.08
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

Know your out-of-pocket cost for care.

All Charges