Heights University Hospital

All Charges

Charge

Type

Setting

Price

POLY SCREW 6.5X55MM

Facility

$3,555.00

Service Code	HCPCS C1713
Hospital Charge Code	270704458
Hospital Revenue Code	278
Min. Negotiated Rate	$533.25
Max. Negotiated Rate	$860.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$711.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$860.31
Rate for Payer: Qualcare PPO/HMO/WC	$533.25

POLY SCREW 6.5X55MM

Facility

$3,555.00

Service Code	HCPCS C1713
Hospital Charge Code	270704458
Hospital Revenue Code	278
Min. Negotiated Rate	$533.25
Max. Negotiated Rate	$1,777.50
Rate for Payer: Aetna Commercial	$1,066.50
Rate for Payer: Aetna Medicare Advantage	$1,066.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$906.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$906.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$711.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$906.52
Rate for Payer: Cigna Commercial	$1,777.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$860.31
Rate for Payer: Qualcare PPO/HMO/WC	$533.25

POLYSONOGRAPHY

Facility

$3,830.45

Service Code	HCPCS 95808
Hospital Charge Code	9500700
Hospital Revenue Code	920
Min. Negotiated Rate	$281.75
Max. Negotiated Rate	$11,682.00
Rate for Payer: Aetna Commercial	$1,149.13
Rate for Payer: Aetna Medicare Advantage	$1,149.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$976.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$976.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$281.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$976.76
Rate for Payer: Cigna Commercial	$2,044.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$497.96
Rate for Payer: Oxford Commercial	$10,292.00
Rate for Payer: Qualcare PPO/HMO/WC	$574.57
Rate for Payer: UnitedHealthcare Commercial	$11,682.00

POLYSONOGRAPHY

Facility

$3,830.45

Service Code	HCPCS 95808
Hospital Charge Code	9500700
Hospital Revenue Code	920
Min. Negotiated Rate	$574.57
Max. Negotiated Rate	$574.57
Rate for Payer: Qualcare PPO/HMO/WC	$574.57

POLYSONOGRAPHY****

Facility

$1,650.00

Service Code	HCPCS 95808
Hospital Charge Code	5400107
Hospital Revenue Code	749
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$2,044.99
Rate for Payer: Aetna Commercial	$495.00
Rate for Payer: Aetna Medicare Advantage	$495.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$420.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$420.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$281.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$420.75
Rate for Payer: Cigna Commercial	$2,044.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$214.50
Rate for Payer: Qualcare PPO/HMO/WC	$247.50

POLYSONOGRAPHY****

Facility

$1,650.00

Service Code	HCPCS 95808
Hospital Charge Code	5400107
Hospital Revenue Code	749
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$247.50
Rate for Payer: Qualcare PPO/HMO/WC	$247.50

POLYSONOGRAPHY W/ CPAP

Facility

$4,596.85

Service Code	HCPCS 95811
Hospital Charge Code	9501285
Hospital Revenue Code	920
Min. Negotiated Rate	$597.59
Max. Negotiated Rate	$11,682.00
Rate for Payer: Aetna Commercial	$1,379.06
Rate for Payer: Aetna Medicare Advantage	$1,379.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,172.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,172.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,242.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,172.20
Rate for Payer: Cigna Commercial	$2,044.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$597.59
Rate for Payer: Oxford Commercial	$10,292.00
Rate for Payer: Qualcare PPO/HMO/WC	$689.53
Rate for Payer: UnitedHealthcare Commercial	$11,682.00

POLYSONOGRAPHY W/ CPAP

Facility

$4,596.85

Service Code	HCPCS 95811
Hospital Charge Code	9501285
Hospital Revenue Code	920
Min. Negotiated Rate	$689.53
Max. Negotiated Rate	$689.53
Rate for Payer: Qualcare PPO/HMO/WC	$689.53

POLYSORB 3-0 ENDO STITCH 48

Facility

$115.90

Hospital Charge Code	270658691
Hospital Revenue Code	272
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$57.95
Rate for Payer: Aetna Commercial	$34.77
Rate for Payer: Aetna Medicare Advantage	$34.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$29.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$29.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$29.55
Rate for Payer: Cigna Commercial	$57.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.07
Rate for Payer: Oxford Commercial	$57.95
Rate for Payer: Qualcare PPO/HMO/WC	$17.39
Rate for Payer: UnitedHealthcare Commercial	$57.95

POLYSORB 3-0 ENDO STITCH 48

Facility

$115.90

Hospital Charge Code	270658691
Hospital Revenue Code	272
Min. Negotiated Rate	$17.39
Max. Negotiated Rate	$17.39
Rate for Payer: Qualcare PPO/HMO/WC	$17.39

POLYSORB 3-0 UNDYED 30 SC-2

Facility

$6.15

Hospital Charge Code	270657581
Hospital Revenue Code	270
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$0.92
Rate for Payer: Qualcare PPO/HMO/WC	$0.92

POLYSORB 3-0 UNDYED 30 SC-2

Facility

$6.15

Hospital Charge Code	270657581
Hospital Revenue Code	270
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: Aetna Medicare Advantage	$1.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.57
Rate for Payer: Cigna Commercial	$3.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.80
Rate for Payer: Oxford Commercial	$3.08
Rate for Payer: Qualcare PPO/HMO/WC	$0.92
Rate for Payer: UnitedHealthcare Commercial	$3.08

POLYSPORIN/10GM

Facility

$51.00

Hospital Charge Code	60633691
Hospital Revenue Code	250
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$15.30
Rate for Payer: Aetna Medicare Advantage	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13.01
Rate for Payer: Cigna Commercial	$25.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.63
Rate for Payer: Oxford Commercial	$25.50
Rate for Payer: Qualcare PPO/HMO/WC	$7.65
Rate for Payer: UnitedHealthcare Commercial	$25.50

POLYSPORIN/10GM

Facility

$51.00

Hospital Charge Code	60633691
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: Qualcare PPO/HMO/WC	$7.65

POLYSPORIN POWDER 10 GM

Facility

$55.60

Hospital Charge Code	60628324W
Hospital Revenue Code	250
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$8.34
Rate for Payer: Qualcare PPO/HMO/WC	$8.34

POLYSPORIN POWDER 10 GM

Facility

$55.60

Hospital Charge Code	60628324W
Hospital Revenue Code	250
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$27.80
Rate for Payer: Aetna Commercial	$16.68
Rate for Payer: Aetna Medicare Advantage	$16.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.18
Rate for Payer: Cigna Commercial	$27.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.23
Rate for Payer: Oxford Commercial	$27.80
Rate for Payer: Qualcare PPO/HMO/WC	$8.34
Rate for Payer: UnitedHealthcare Commercial	$27.80

POLY-VI-FLOR/0.25MG/1ML

Facility

$60.00

Hospital Charge Code	60633671
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00

POLY-VI-FLOR/0.25MG/1ML

Facility

$60.00

Hospital Charge Code	60633671
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Aetna Medicare Advantage	$18.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.30
Rate for Payer: Cigna Commercial	$30.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.80
Rate for Payer: Oxford Commercial	$30.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00
Rate for Payer: UnitedHealthcare Commercial	$30.00

POLY-VI-FLOR/0.5MG/1ML

Facility

$56.00

Hospital Charge Code	60633673
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$8.40
Rate for Payer: Qualcare PPO/HMO/WC	$8.40

POLY-VI-FLOR/0.5MG/1ML

Facility

$56.00

Hospital Charge Code	60633673
Hospital Revenue Code	250
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$16.80
Rate for Payer: Aetna Medicare Advantage	$16.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.28
Rate for Payer: Cigna Commercial	$28.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.28
Rate for Payer: Oxford Commercial	$28.00
Rate for Payer: Qualcare PPO/HMO/WC	$8.40
Rate for Payer: UnitedHealthcare Commercial	$28.00

POLY-VI-FLOR/0.5MG/TAB

Facility

$71.00

Hospital Charge Code	60633674
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$10.65
Rate for Payer: Qualcare PPO/HMO/WC	$10.65

POLY-VI-FLOR/0.5MG/TAB

Facility

$71.00

Hospital Charge Code	60633674
Hospital Revenue Code	250
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$35.50
Rate for Payer: Aetna Commercial	$21.30
Rate for Payer: Aetna Medicare Advantage	$21.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.11
Rate for Payer: Cigna Commercial	$35.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.23
Rate for Payer: Oxford Commercial	$35.50
Rate for Payer: Qualcare PPO/HMO/WC	$10.65
Rate for Payer: UnitedHealthcare Commercial	$35.50

POLY-VI-FLOR/1MG/TAB

Facility

$71.00

Hospital Charge Code	60633672
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$10.65
Rate for Payer: Qualcare PPO/HMO/WC	$10.65

POLY-VI-FLOR/1MG/TAB

Facility

$71.00

Hospital Charge Code	60633672
Hospital Revenue Code	250
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$35.50
Rate for Payer: Aetna Commercial	$21.30
Rate for Payer: Aetna Medicare Advantage	$21.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.11
Rate for Payer: Cigna Commercial	$35.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.23
Rate for Payer: Oxford Commercial	$35.50
Rate for Payer: Qualcare PPO/HMO/WC	$10.65
Rate for Payer: UnitedHealthcare Commercial	$35.50

POLY-VI-FLOR W/IRON/0.25M

Facility

$40.00

Hospital Charge Code	60633675
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.00

Know your out-of-pocket cost for care.

All Charges