Heights University Hospital

All Charges

Charge

Type

Setting

Price

PROVAY BLUE 0.5% 10MG/ML 10 ML

Facility

$1,867.02

Service Code	HCPCS Q9968
Hospital Charge Code	606390266
Hospital Revenue Code	636
Min. Negotiated Rate	$280.05
Max. Negotiated Rate	$451.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$451.82
Rate for Payer: Qualcare PPO/HMO/WC	$280.05

PROVAY BLUE 0.5% 10MG/ML 10 ML

Facility

$1,867.02

Service Code	HCPCS Q9968
Hospital Charge Code	606390266
Hospital Revenue Code	636
Min. Negotiated Rate	$280.05
Max. Negotiated Rate	$560.11
Rate for Payer: Aetna Commercial	$560.11
Rate for Payer: Aetna Medicare Advantage	$560.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$476.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$476.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$476.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$451.82
Rate for Payer: Qualcare PPO/HMO/WC	$280.05

PROVENDA AMNIOTIC MEMBR 3X3CM

Facility

$13,180.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694280
Hospital Revenue Code	278
Min. Negotiated Rate	$1,977.00
Max. Negotiated Rate	$3,189.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,636.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,189.56
Rate for Payer: Qualcare PPO/HMO/WC	$1,977.00

PROVENDA AMNIOTIC MEMBR 3X3CM

Facility

$13,180.00

Service Code	HCPCS Q4205
Hospital Charge Code	270694280
Hospital Revenue Code	278
Min. Negotiated Rate	$296.35
Max. Negotiated Rate	$3,954.00
Rate for Payer: Aetna Commercial	$3,954.00
Rate for Payer: Aetna Medicare Advantage	$3,954.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,360.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,360.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,636.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,360.90
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,189.56
Rate for Payer: Qualcare PPO/HMO/WC	$1,977.00

PROVENTIL/0.83MG/1ML

Facility

$3.00

Hospital Charge Code	60633776
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PROVENTIL/0.83MG/1ML

Facility

$3.00

Hospital Charge Code	60633776
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

PROVENTIL/17GM

Facility

$118.00

Hospital Charge Code	60633773
Hospital Revenue Code	250
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$35.40
Rate for Payer: Aetna Medicare Advantage	$35.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.09
Rate for Payer: Cigna Commercial	$59.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15.34
Rate for Payer: Oxford Commercial	$59.00
Rate for Payer: Qualcare PPO/HMO/WC	$17.70
Rate for Payer: UnitedHealthcare Commercial	$59.00

PROVENTIL/17GM

Facility

$118.00

Hospital Charge Code	60633773
Hospital Revenue Code	250
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$17.70
Rate for Payer: Qualcare PPO/HMO/WC	$17.70

PROVENTIL/2MG/TAB

Facility

$39.40

Service Code	NDC 53489017601
Hospital Charge Code	60633774
Hospital Revenue Code	250
Min. Negotiated Rate	$5.91
Max. Negotiated Rate	$5.91
Rate for Payer: Qualcare PPO/HMO/WC	$5.91

PROVENTIL/2MG/TAB

Facility

$39.40

Service Code	NDC 53489017601
Hospital Charge Code	60633774
Hospital Revenue Code	250
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$19.70
Rate for Payer: Aetna Commercial	$11.82
Rate for Payer: Aetna Medicare Advantage	$11.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.05
Rate for Payer: Cigna Commercial	$19.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.12
Rate for Payer: Oxford Commercial	$19.70
Rate for Payer: Qualcare PPO/HMO/WC	$5.91
Rate for Payer: UnitedHealthcare Commercial	$19.70

PROVENTIL/4MG/TAB

Facility

$47.24

Service Code	NDC 51079065820
Hospital Charge Code	60633775
Hospital Revenue Code	250
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$7.09
Rate for Payer: Qualcare PPO/HMO/WC	$7.09

PROVENTIL/4MG/TAB

Facility

$47.24

Service Code	NDC 51079065820
Hospital Charge Code	60633775
Hospital Revenue Code	250
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$23.62
Rate for Payer: Aetna Commercial	$14.17
Rate for Payer: Aetna Medicare Advantage	$14.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.05
Rate for Payer: Cigna Commercial	$23.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.14
Rate for Payer: Oxford Commercial	$23.62
Rate for Payer: Qualcare PPO/HMO/WC	$7.09
Rate for Payer: UnitedHealthcare Commercial	$23.62

PROVENTIL HFA INHALER

Facility

$80.00

Hospital Charge Code	60635214
Hospital Revenue Code	250
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$24.00
Rate for Payer: Aetna Medicare Advantage	$24.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$20.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$20.40
Rate for Payer: Cigna Commercial	$40.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.40
Rate for Payer: Oxford Commercial	$40.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00
Rate for Payer: UnitedHealthcare Commercial	$40.00

PROVENTIL HFA INHALER

Facility

$80.00

Hospital Charge Code	60635214
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00

PROVENTIL LIQUID/16OZ

Facility

$152.00

Hospital Charge Code	60634592
Hospital Revenue Code	250
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$22.80
Rate for Payer: Qualcare PPO/HMO/WC	$22.80

PROVENTIL LIQUID/16OZ

Facility

$152.00

Hospital Charge Code	60634592
Hospital Revenue Code	250
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare Advantage	$45.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$38.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$38.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$38.76
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.76
Rate for Payer: Oxford Commercial	$76.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.80
Rate for Payer: UnitedHealthcare Commercial	$76.00

PROVENTIL REPETABS

Facility

$6.00

Hospital Charge Code	60634862
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.78
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$3.00

PROVENTIL REPETABS

Facility

$6.00

Hospital Charge Code	60634862
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

PROVENTIL REPETABS U/D

Facility

$6.00

Hospital Charge Code	60634861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

PROVENTIL REPETABS U/D

Facility

$6.00

Hospital Charge Code	60634861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.78
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$3.00

PROVERA/2.5MG/TAB

Facility

$3.00

Hospital Charge Code	60633778
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PROVERA/2.5MG/TAB

Facility

$3.00

Hospital Charge Code	60633778
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

PROVERA/2.5MG/TAB

Facility

$3.00

Hospital Charge Code	60633777
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PROVERA/2.5MG/TAB

Facility

$3.00

Hospital Charge Code	60633777
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

PROVIGIL 100MG

Facility

$6.00

Hospital Charge Code	60635497
Hospital Revenue Code	250
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.78
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$3.00

Know your out-of-pocket cost for care.

All Charges