Heights University Hospital

All Charges

Charge

Type

Setting

Price

PSEUDOEPHEDRINE/30MG/TAB

Facility

$1.00

Hospital Charge Code	60633783
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.30
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.13
Rate for Payer: Oxford Commercial	$0.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.50

PSEUDOEPHEDRINE/30MG/TAB

Facility

$3.00

Hospital Charge Code	60633785
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

PSEUDOEPHEDRINE/30MG/TAB

Facility

$1.00

Hospital Charge Code	60633781
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.30
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.13
Rate for Payer: Oxford Commercial	$0.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.50

PSEUDOEPHEDRINE/30MG/TAB

Facility

$1.00

Hospital Charge Code	60633781
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

PSEUDOEPHEDRINE 30 MG TAB UD

Facility

$4.00

Service Code	NDC 904505359
Hospital Charge Code	60627465
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

PSEUDOEPHEDRINE 30 MG TAB UD

Facility

$4.00

Service Code	NDC 904505359
Hospital Charge Code	60627465
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PSEUDOEPHEDRINE/60MG/TAB

Facility

$3.00

Hospital Charge Code	60633784
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

PSEUDOEPHEDRINE/60MG/TAB

Facility

$1.00

Hospital Charge Code	60633782
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

PSEUDOEPHEDRINE/60MG/TAB

Facility

$1.00

Hospital Charge Code	60633782
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.30
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.13
Rate for Payer: Oxford Commercial	$0.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.50

PSEUDOEPHEDRINE/60MG/TAB

Facility

$3.00

Hospital Charge Code	60633784
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

PSEUDOEPHEDRINE 60 MG TAB UD

Facility

$4.00

Service Code	NDC 904512559
Hospital Charge Code	60627467
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

PSEUDOEPHEDRINE 60 MG TAB UD

Facility

$4.00

Service Code	NDC 904512559
Hospital Charge Code	60627467
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PSEUDOEPHEDRINE CHLRPHN LQ 4OZ

Facility

$41.60

Hospital Charge Code	6004725
Hospital Revenue Code	251
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna Commercial	$12.48
Rate for Payer: Aetna Medicare Advantage	$12.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.61
Rate for Payer: Cigna Commercial	$20.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.41
Rate for Payer: Oxford Commercial	$20.80
Rate for Payer: Qualcare PPO/HMO/WC	$6.24
Rate for Payer: UnitedHealthcare Commercial	$20.80

PSEUDOEPHEDRINE CHLRPHN LQ 4OZ

Facility

$41.60

Hospital Charge Code	6004725
Hospital Revenue Code	251
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$6.24
Rate for Payer: Qualcare PPO/HMO/WC	$6.24

PSEUDOEPHEDRINE RIPROL LQ 4OZ

Facility

$15.40

Hospital Charge Code	6013189
Hospital Revenue Code	251
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$7.70
Rate for Payer: Aetna Commercial	$4.62
Rate for Payer: Aetna Medicare Advantage	$4.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.93
Rate for Payer: Cigna Commercial	$7.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.00
Rate for Payer: Oxford Commercial	$7.70
Rate for Payer: Qualcare PPO/HMO/WC	$2.31
Rate for Payer: UnitedHealthcare Commercial	$7.70

PSEUDOEPHEDRINE RIPROL LQ 4OZ

Facility

$15.40

Hospital Charge Code	6013189
Hospital Revenue Code	251
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$2.31
Rate for Payer: Qualcare PPO/HMO/WC	$2.31

PSEUDOEPHEDRINE SOLN 15MG/5ML

Facility

$4.00

Service Code	NDC 50580053604
Hospital Charge Code	606390565
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PSEUDOEPHEDRINE SOLN 15MG/5ML

Facility

$4.00

Service Code	NDC 50580053604
Hospital Charge Code	606390565
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

PSEUDOEPHEDRINE SYRP 30MG/5ML

Facility

$10.25

Hospital Charge Code	60627466
Hospital Revenue Code	251
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$5.12
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: Aetna Medicare Advantage	$3.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.61
Rate for Payer: Cigna Commercial	$5.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.33
Rate for Payer: Oxford Commercial	$5.12
Rate for Payer: Qualcare PPO/HMO/WC	$1.54
Rate for Payer: UnitedHealthcare Commercial	$5.12

PSEUDOEPHEDRINE SYRP 30MG/5ML

Facility

$10.25

Hospital Charge Code	60627466
Hospital Revenue Code	251
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.54

PS FEM STAB COMP TRIATH SZ2 LT

Facility

$10,774.35

Service Code	HCPCS C1776
Hospital Charge Code	270694193
Hospital Revenue Code	278
Min. Negotiated Rate	$1,616.15
Max. Negotiated Rate	$2,607.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,154.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,607.39
Rate for Payer: Qualcare PPO/HMO/WC	$1,616.15

PS FEM STAB COMP TRIATH SZ2 LT

Facility

$10,774.35

Service Code	HCPCS C1776
Hospital Charge Code	270694193
Hospital Revenue Code	278
Min. Negotiated Rate	$1,616.15
Max. Negotiated Rate	$5,387.18
Rate for Payer: Aetna Commercial	$3,232.30
Rate for Payer: Aetna Medicare Advantage	$3,232.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,747.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,747.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,154.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,747.46
Rate for Payer: Cigna Commercial	$5,387.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,607.39
Rate for Payer: Qualcare PPO/HMO/WC	$1,616.15

PSF TRIATHLON PS RT #4

Facility

$10,529.45

Service Code	HCPCS C1776
Hospital Charge Code	270695677
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.42
Max. Negotiated Rate	$2,548.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,105.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,548.13
Rate for Payer: Qualcare PPO/HMO/WC	$1,579.42

PSF TRIATHLON PS RT #4

Facility

$10,529.45

Service Code	HCPCS C1776
Hospital Charge Code	270695677
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.42
Max. Negotiated Rate	$5,264.73
Rate for Payer: Aetna Commercial	$3,158.84
Rate for Payer: Aetna Medicare Advantage	$3,158.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,685.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,685.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,105.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,685.01
Rate for Payer: Cigna Commercial	$5,264.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,548.13
Rate for Payer: Qualcare PPO/HMO/WC	$1,579.42

PSG 1-3

Facility

$4,688.00

Service Code	HCPCS 95808
Hospital Charge Code	90000030
Hospital Revenue Code	920
Min. Negotiated Rate	$703.20
Max. Negotiated Rate	$703.20
Rate for Payer: Qualcare PPO/HMO/WC	$703.20

Know your out-of-pocket cost for care.

All Charges