Heights University Hospital

All Charges

Charge

Type

Setting

Price

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.25
Max. Negotiated Rate	$3,937.50
Rate for Payer: Aetna Commercial	$2,362.50
Rate for Payer: Aetna Medicare Advantage	$2,362.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,008.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,008.12
Rate for Payer: Cigna Commercial	$3,937.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25

POLY GLENOLD W/PEG LG

Facility

$7,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270672691
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.25
Max. Negotiated Rate	$1,905.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,575.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,905.75
Rate for Payer: Qualcare PPO/HMO/WC	$1,181.25

POLY INFINITY SZ 4+ 7MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270678156
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INFINITY SZ 4+ 7MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270678156
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$2,925.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ1/1+ 6MM

Facility

$10,145.00

Hospital Charge Code	270670886
Hospital Revenue Code	278
Min. Negotiated Rate	$1,521.75
Max. Negotiated Rate	$2,455.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,029.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,455.09
Rate for Payer: Qualcare PPO/HMO/WC	$1,521.75

POLY INSERT SZ1/1+ 6MM

Facility

$10,145.00

Hospital Charge Code	270670886
Hospital Revenue Code	278
Min. Negotiated Rate	$1,521.75
Max. Negotiated Rate	$5,072.50
Rate for Payer: Aetna Commercial	$3,043.50
Rate for Payer: Aetna Medicare Advantage	$3,043.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,586.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,586.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,029.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,586.97
Rate for Payer: Cigna Commercial	$5,072.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,455.09
Rate for Payer: Qualcare PPO/HMO/WC	$1,521.75

POLY INSERT SZ 1/1+ 8MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270675066
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$2,925.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ 1/1+ 8MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270675066
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ 2+ 6MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270676974
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$4,875.00
Rate for Payer: Aetna Commercial	$2,925.00
Rate for Payer: Aetna Medicare Advantage	$2,925.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,486.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,486.25
Rate for Payer: Cigna Commercial	$4,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY INSERT SZ 2+ 6MM

Facility

$9,750.00

Service Code	HCPCS C1776
Hospital Charge Code	270676974
Hospital Revenue Code	278
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$2,359.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,359.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,462.50

POLY LINER HIGH WALL/SZ F 36MM

Facility

$6,000.00

Service Code	HCPCS C1765
Hospital Charge Code	270705045
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

POLY LINER HIGH WALL/SZ F 36MM

Facility

$6,000.00

Service Code	HCPCS C1765
Hospital Charge Code	270705045
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$1,800.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

POLY LINER HIGH WALL SZ G

Facility

$32,500.00

Hospital Charge Code	270702513
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$16,250.00
Rate for Payer: Aetna Commercial	$9,750.00
Rate for Payer: Aetna Medicare Advantage	$9,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,287.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,287.50
Rate for Payer: Cigna Commercial	$16,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

POLY LINER HIGH WALL SZ G

Facility

$32,500.00

Hospital Charge Code	270702513
Hospital Revenue Code	278
Min. Negotiated Rate	$4,875.00
Max. Negotiated Rate	$7,865.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,865.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,875.00

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535
Hospital Revenue Code	272
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna Commercial	$1.64
Rate for Payer: Aetna Medicare Advantage	$1.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.39
Rate for Payer: Cigna Commercial	$2.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.71
Rate for Payer: Oxford Commercial	$2.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.82
Rate for Payer: UnitedHealthcare Commercial	$2.73

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535W
Hospital Revenue Code	272
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna Commercial	$1.64
Rate for Payer: Aetna Medicare Advantage	$1.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.39
Rate for Payer: Cigna Commercial	$2.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.71
Rate for Payer: Oxford Commercial	$2.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.82
Rate for Payer: UnitedHealthcare Commercial	$2.73

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535
Hospital Revenue Code	272
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.82

POLYMEM OVAL FILM ADHESIVE 2X

Facility

$5.45

Hospital Charge Code	270684535W
Hospital Revenue Code	272
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.82

POLYMOX/125MG/5ML

Facility

$18.00

Hospital Charge Code	60633689
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$2.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

POLYMOX/125MG/5ML

Facility

$18.00

Hospital Charge Code	60633689
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.34
Rate for Payer: Oxford Commercial	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Commercial	$9.00

POLYMOX/250MG/5ML

Facility

$18.00

Hospital Charge Code	60633690
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$2.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.70

POLYMOX/250MG/5ML

Facility

$18.00

Hospital Charge Code	60633690
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Aetna Medicare Advantage	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.59
Rate for Payer: Cigna Commercial	$9.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.34
Rate for Payer: Oxford Commercial	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.70
Rate for Payer: UnitedHealthcare Commercial	$9.00

POLYMYXIN B 500000 U INJ

Facility

$90.45

Service Code	NDC 39822016605
Hospital Charge Code	60630050
Hospital Revenue Code	250
Min. Negotiated Rate	$13.57
Max. Negotiated Rate	$13.57
Rate for Payer: Qualcare PPO/HMO/WC	$13.57

POLYMYXIN B 500000 U INJ

Facility

$90.45

Service Code	NDC 39822016605
Hospital Charge Code	60630050
Hospital Revenue Code	250
Min. Negotiated Rate	$11.76
Max. Negotiated Rate	$45.23
Rate for Payer: Aetna Commercial	$27.14
Rate for Payer: Aetna Medicare Advantage	$27.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.06
Rate for Payer: Cigna Commercial	$45.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.76
Rate for Payer: Oxford Commercial	$45.23
Rate for Payer: Qualcare PPO/HMO/WC	$13.57
Rate for Payer: UnitedHealthcare Commercial	$45.23

POLYMYXIN BACIT OINT OPH 3.5GM

Facility

$125.45

Hospital Charge Code	6004485
Hospital Revenue Code	251
Min. Negotiated Rate	$18.82
Max. Negotiated Rate	$18.82
Rate for Payer: Qualcare PPO/HMO/WC	$18.82

Know your out-of-pocket cost for care.

All Charges