Heights University Hospital

All Charges

Charge

Type

Setting

Price

POLY-VI-FLOR W/IRON/0.25M

Facility

$40.00

Hospital Charge Code	60633675
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.20
Rate for Payer: Cigna Commercial	$20.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.20
Rate for Payer: Oxford Commercial	$20.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.00
Rate for Payer: UnitedHealthcare Commercial	$20.00

POLY-VI-FLOR W/IRON/0.5MG

Facility

$71.00

Hospital Charge Code	60633677
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/0.5MG

Facility

$56.00

Hospital Charge Code	60633676
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 W/IRON/0.5MG

Facility

$71.00

Hospital Charge Code	60633677
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 W/IRON/0.5MG

Facility

$56.00

Hospital Charge Code	60633676
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 W/IRON/1MG/1

Facility

$71.00

Hospital Charge Code	60633678
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 W/IRON/1MG/1

Facility

$71.00

Hospital Charge Code	60633678
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

POLYVINYL ALCOHOL POVIDONE OPH

Facility

$29.35

Service Code	NDC 536197072
Hospital Charge Code	60628094
Hospital Revenue Code	250
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$4.40
Rate for Payer: Qualcare PPO/HMO/WC	$4.40

POLYVINYL ALCOHOL POVIDONE OPH

Facility

$29.35

Service Code	NDC 536197072
Hospital Charge Code	60628094
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$14.68
Rate for Payer: Aetna Commercial	$8.80
Rate for Payer: Aetna Medicare Advantage	$8.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.48
Rate for Payer: Cigna Commercial	$14.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.82
Rate for Payer: Oxford Commercial	$14.68
Rate for Payer: Qualcare PPO/HMO/WC	$4.40
Rate for Payer: UnitedHealthcare Commercial	$14.68

POLYVINYL ALCOHOL SOL OPH 30ML

Facility

$34.60

Hospital Charge Code	6004501
Hospital Revenue Code	251
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$5.19
Rate for Payer: Qualcare PPO/HMO/WC	$5.19

POLYVINYL ALCOHOL SOL OPH 30ML

Facility

$34.60

Hospital Charge Code	6004501
Hospital Revenue Code	251
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$17.30
Rate for Payer: Aetna Commercial	$10.38
Rate for Payer: Aetna Medicare Advantage	$10.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.82
Rate for Payer: Cigna Commercial	$17.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$17.30
Rate for Payer: Qualcare PPO/HMO/WC	$5.19
Rate for Payer: UnitedHealthcare Commercial	$17.30

POLY VI SOL DROP

Facility

$0.66

Hospital Charge Code	6063943268
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Qualcare PPO/HMO/WC	$0.10

POLY VI SOL DROP

Facility

$4.00

Service Code	NDC 536845080
Hospital Charge Code	6063943231
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

POLY VI SOL DROP

Facility

$4.00

Service Code	NDC 536845080
Hospital Charge Code	6063943231
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

POLY VI SOL DROP

Facility

$0.66

Hospital Charge Code	6063943268
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna Commercial	$0.20
Rate for Payer: Aetna Medicare Advantage	$0.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.17
Rate for Payer: Cigna Commercial	$0.33
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.09
Rate for Payer: Oxford Commercial	$0.33
Rate for Payer: Qualcare PPO/HMO/WC	$0.10
Rate for Payer: UnitedHealthcare Commercial	$0.33

PONOCAINE 2% SOL 30ML

Facility

$84.00

Hospital Charge Code	60635631
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Qualcare PPO/HMO/WC	$12.60

PONOCAINE 2% SOL 30ML

Facility

$84.00

Hospital Charge Code	60635631
Hospital Revenue Code	250
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Aetna Medicare Advantage	$25.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.42
Rate for Payer: Cigna Commercial	$42.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.92
Rate for Payer: Oxford Commercial	$42.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.60
Rate for Payer: UnitedHealthcare Commercial	$42.00

PONSTEL/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633692
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

PONSTEL/250MG/CAP

Facility

$3.00

Hospital Charge Code	60633692
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PONTOCAINE 2%/30ML

Facility

$97.00

Hospital Charge Code	60633693
Hospital Revenue Code	250
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$14.55
Rate for Payer: Qualcare PPO/HMO/WC	$14.55

PONTOCAINE 2%/30ML

Facility

$97.00

Hospital Charge Code	60633693
Hospital Revenue Code	250
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$48.50
Rate for Payer: Aetna Commercial	$29.10
Rate for Payer: Aetna Medicare Advantage	$29.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.73
Rate for Payer: Cigna Commercial	$48.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.61
Rate for Payer: Oxford Commercial	$48.50
Rate for Payer: Qualcare PPO/HMO/WC	$14.55
Rate for Payer: UnitedHealthcare Commercial	$48.50

POOLING CHARGE

Facility

$390.00

Service Code	HCPCS 86965
Hospital Charge Code	3100519
Hospital Revenue Code	300
Min. Negotiated Rate	$50.70
Max. Negotiated Rate	$405.73
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) NJ Health	$56.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$99.45
Rate for Payer: Cigna Commercial	$405.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$114.00

POOLING CHARGE

Facility

$390.00

Service Code	HCPCS 86965
Hospital Charge Code	3100519
Hospital Revenue Code	300
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

POOLING OF PLATELETS OR BLOOD

Facility

$149.00

Service Code	HCPCS 86965
Hospital Charge Code	38471081
Hospital Revenue Code	309
Min. Negotiated Rate	$22.35
Max. Negotiated Rate	$22.35
Rate for Payer: Qualcare PPO/HMO/WC	$22.35

POOLING OF PLATELETS OR BLOOD

Facility

$149.00

Service Code	HCPCS 86965
Hospital Charge Code	38471081
Hospital Revenue Code	309
Min. Negotiated Rate	$19.37
Max. Negotiated Rate	$405.73
Rate for Payer: Aetna Commercial	$44.70
Rate for Payer: Aetna Medicare Advantage	$44.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$37.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$37.99
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	$37.99
Rate for Payer: Cigna Commercial	$405.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.37
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.35
Rate for Payer: UnitedHealthcare Commercial	$114.00

Know your out-of-pocket cost for care.

All Charges