Heights University Hospital

All Charges

Charge

Type

Setting

Price

SIMETHICONE LQ 40MG/.6ML 30ML

Facility

$4.00

Service Code	NDC 536222075
Hospital Charge Code	6004915
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

SIMILAC INFANT FORMULA 6O ML

Facility

$104.00

Hospital Charge Code	60628741
Hospital Revenue Code	270
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$15.60
Rate for Payer: Qualcare PPO/HMO/WC	$15.60

SIMILAC INFANT FORMULA 6O ML

Facility

$104.00

Hospital Charge Code	60628741
Hospital Revenue Code	270
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$31.20
Rate for Payer: Aetna Medicare Advantage	$31.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.52
Rate for Payer: Cigna Commercial	$52.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.52
Rate for Payer: Oxford Commercial	$52.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.60
Rate for Payer: UnitedHealthcare Commercial	$52.00

SIMILAC PROBIOTIC TRI-BLEND

Facility

$37.92

Service Code	NDC 99999999999
Hospital Charge Code	606390389
Hospital Revenue Code	250
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$18.96
Rate for Payer: Aetna Commercial	$11.38
Rate for Payer: Aetna Medicare Advantage	$11.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.67
Rate for Payer: Cigna Commercial	$18.96
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.93
Rate for Payer: Oxford Commercial	$18.96
Rate for Payer: Qualcare PPO/HMO/WC	$5.69
Rate for Payer: UnitedHealthcare Commercial	$18.96

SIMILAC PROBIOTIC TRI-BLEND

Facility

$37.92

Service Code	NDC 99999999999
Hospital Charge Code	606390389
Hospital Revenue Code	250
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$5.69
Rate for Payer: Qualcare PPO/HMO/WC	$5.69

SI MOCHIX-5CC /GRANULE 1-2MM

Facility

$10,105.00

Service Code	HCPCS C1765
Hospital Charge Code	270704783
Hospital Revenue Code	278
Min. Negotiated Rate	$1,515.75
Max. Negotiated Rate	$2,445.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,021.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,445.41
Rate for Payer: Qualcare PPO/HMO/WC	$1,515.75

SI MOCHIX-5CC /GRANULE 1-2MM

Facility

$10,105.00

Service Code	HCPCS C1765
Hospital Charge Code	270704783
Hospital Revenue Code	278
Min. Negotiated Rate	$1,515.75
Max. Negotiated Rate	$5,052.50
Rate for Payer: Aetna Commercial	$3,031.50
Rate for Payer: Aetna Medicare Advantage	$3,031.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,576.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,576.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,021.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,576.78
Rate for Payer: Cigna Commercial	$5,052.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,445.41
Rate for Payer: Qualcare PPO/HMO/WC	$1,515.75

SIMPLE BLADDER IRRIGATE LAVAGE

Facility

$26,701.00

Service Code	HCPCS 25545
Hospital Charge Code	16000618
Hospital Revenue Code	360
Min. Negotiated Rate	$4,005.15
Max. Negotiated Rate	$4,005.15
Rate for Payer: Qualcare PPO/HMO/WC	$4,005.15

SIMPLE BLADDER IRRIGATE LAVAGE

Facility

$26,701.00

Service Code	HCPCS 25545
Hospital Charge Code	16000618
Hospital Revenue Code	360
Min. Negotiated Rate	$1,864.00
Max. Negotiated Rate	$17,279.91
Rate for Payer: Aetna Commercial	$8,010.30
Rate for Payer: Aetna Medicare Advantage	$8,010.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,808.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,808.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,808.76
Rate for Payer: Cigna Commercial	$17,279.91
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,471.13
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,005.15
Rate for Payer: UnitedHealthcare Commercial	$9,851.00

SIMPLE CYSTOMETROGRAM

Facility

$4,978.50

Service Code	HCPCS 51725
Hospital Charge Code	1600000534
Hospital Revenue Code	360
Min. Negotiated Rate	$594.98
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$1,493.55
Rate for Payer: Aetna Medicare Advantage	$1,493.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,269.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,269.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,269.52
Rate for Payer: Cigna Commercial	$594.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$647.21
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$746.77
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

SIMPLE CYSTOMETROGRAM

Facility

$4,978.50

Service Code	HCPCS 51725
Hospital Charge Code	1600000534
Hospital Revenue Code	360
Min. Negotiated Rate	$746.77
Max. Negotiated Rate	$746.77
Rate for Payer: Qualcare PPO/HMO/WC	$746.77

SIMPLE OTHR LOC LAC REP TO 2.5

Facility

$1,473.00

Service Code	HCPCS 12001
Hospital Charge Code	1600000706
Hospital Revenue Code	360
Min. Negotiated Rate	$191.49
Max. Negotiated Rate	$1,864.00
Rate for Payer: Aetna Commercial	$441.90
Rate for Payer: Aetna Medicare Advantage	$441.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$375.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$375.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$375.62
Rate for Payer: Cigna Commercial	$477.79
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$191.49
Rate for Payer: Oxford Commercial	$1,487.00
Rate for Payer: Qualcare PPO/HMO/WC	$220.95
Rate for Payer: UnitedHealthcare Commercial	$1,686.00

SIMPLE OTHR LOC LAC REP TO 2.5

Facility

$1,473.00

Service Code	HCPCS 12001
Hospital Charge Code	1600000706
Hospital Revenue Code	360
Min. Negotiated Rate	$220.95
Max. Negotiated Rate	$220.95
Rate for Payer: Qualcare PPO/HMO/WC	$220.95

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$35,214.06

Service Code	MSDRG 194
Min. Negotiated Rate	$8,794.45
Max. Negotiated Rate	$35,214.06
Rate for Payer: Aetna Commercial	$27,174.85
Rate for Payer: Aetna Medicare Advantage	$8,794.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22,604.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22,604.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$11,738.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22,604.94
Rate for Payer: Cigna Commercial	$17,343.77
Rate for Payer: Cigna Medicare Advantage	$11,738.02
Rate for Payer: Clover Medicare Advantage	$11,151.12
Rate for Payer: EmblemHealth Commercial	$35,214.06
Rate for Payer: Humana Medicare Advantage	$12,090.16
Rate for Payer: Oxford Commercial	$10,839.35
Rate for Payer: UnitedHealthcare Commercial	$12,303.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$11,738.02
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$12,442.30
Rate for Payer: Wellcare Medicare Advantage	$11,738.02

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$49,973.64

Service Code	MSDRG 193
Min. Negotiated Rate	$14,343.50
Max. Negotiated Rate	$49,973.64
Rate for Payer: Aetna Commercial	$44,321.42
Rate for Payer: Aetna Medicare Advantage	$14,343.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36,664.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36,664.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16,657.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36,664.11
Rate for Payer: Cigna Commercial	$28,287.20
Rate for Payer: Cigna Medicare Advantage	$16,657.88
Rate for Payer: Clover Medicare Advantage	$15,824.99
Rate for Payer: EmblemHealth Commercial	$49,973.64
Rate for Payer: Humana Medicare Advantage	$17,157.62
Rate for Payer: Oxford Commercial	$17,678.68
Rate for Payer: UnitedHealthcare Commercial	$20,066.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$16,657.88
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$17,657.35
Rate for Payer: Wellcare Medicare Advantage	$16,657.88

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$30,064.89

Service Code	MSDRG 195
Min. Negotiated Rate	$6,858.56
Max. Negotiated Rate	$30,064.89
Rate for Payer: Aetna Commercial	$21,192.95
Rate for Payer: Aetna Medicare Advantage	$6,858.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17,367.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17,367.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10,021.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17,367.21
Rate for Payer: Cigna Commercial	$13,525.95
Rate for Payer: Cigna Medicare Advantage	$10,021.63
Rate for Payer: Clover Medicare Advantage	$9,520.55
Rate for Payer: EmblemHealth Commercial	$30,064.89
Rate for Payer: Humana Medicare Advantage	$10,322.28
Rate for Payer: Oxford Commercial	$8,453.33
Rate for Payer: UnitedHealthcare Commercial	$9,595.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$10,021.63
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$10,622.93
Rate for Payer: Wellcare Medicare Advantage	$10,021.63

SIMPLIFY DISC SIZE 1 HT 4

Facility

$26,991.25

Service Code	HCPCS C1713
Hospital Charge Code	270704796
Hospital Revenue Code	278
Min. Negotiated Rate	$4,048.69
Max. Negotiated Rate	$13,495.62
Rate for Payer: Aetna Commercial	$8,097.38
Rate for Payer: Aetna Medicare Advantage	$8,097.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,882.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,882.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,398.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,882.77
Rate for Payer: Cigna Commercial	$13,495.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,531.88
Rate for Payer: Qualcare PPO/HMO/WC	$4,048.69

SIMPLIFY DISC SIZE 1 HT 4

Facility

$26,991.25

Service Code	HCPCS C1713
Hospital Charge Code	270704796
Hospital Revenue Code	278
Min. Negotiated Rate	$4,048.69
Max. Negotiated Rate	$6,531.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,398.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,531.88
Rate for Payer: Qualcare PPO/HMO/WC	$4,048.69

SIMPLIFY DISC SZ 1 HT 4

Facility

$57,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270695024
Hospital Revenue Code	278
Min. Negotiated Rate	$8,625.00
Max. Negotiated Rate	$13,915.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13,915.00
Rate for Payer: Qualcare PPO/HMO/WC	$8,625.00

SIMPLIFY DISC SZ 1 HT 4

Facility

$57,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270695024
Hospital Revenue Code	278
Min. Negotiated Rate	$8,625.00
Max. Negotiated Rate	$28,750.00
Rate for Payer: Aetna Commercial	$17,250.00
Rate for Payer: Aetna Medicare Advantage	$17,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14,662.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14,662.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14,662.50
Rate for Payer: Cigna Commercial	$28,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13,915.00
Rate for Payer: Qualcare PPO/HMO/WC	$8,625.00

SIMPLIFY DISC SZ 3 HT 5

Facility

$26,991.25

Service Code	HCPCS C1713
Hospital Charge Code	270703756
Hospital Revenue Code	278
Min. Negotiated Rate	$4,048.69
Max. Negotiated Rate	$6,531.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,398.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,531.88
Rate for Payer: Qualcare PPO/HMO/WC	$4,048.69

SIMPLIFY DISC SZ 3 HT 5

Facility

$26,991.25

Service Code	HCPCS C1713
Hospital Charge Code	270703756
Hospital Revenue Code	278
Min. Negotiated Rate	$4,048.69
Max. Negotiated Rate	$13,495.62
Rate for Payer: Aetna Commercial	$8,097.38
Rate for Payer: Aetna Medicare Advantage	$8,097.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,882.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,882.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,398.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,882.77
Rate for Payer: Cigna Commercial	$13,495.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,531.88
Rate for Payer: Qualcare PPO/HMO/WC	$4,048.69

SIMPL SOLO SYST W/SHOW 0067700

Facility

$247.98

Hospital Charge Code	270640026
Hospital Revenue Code	272
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$37.20
Rate for Payer: Qualcare PPO/HMO/WC	$37.20

SIMPL SOLO SYST W/SHOW 0067700

Facility

$247.98

Hospital Charge Code	270640026
Hospital Revenue Code	272
Min. Negotiated Rate	$32.24
Max. Negotiated Rate	$123.99
Rate for Payer: Aetna Commercial	$74.39
Rate for Payer: Aetna Medicare Advantage	$74.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$63.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$63.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$63.23
Rate for Payer: Cigna Commercial	$123.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.24
Rate for Payer: Oxford Commercial	$123.99
Rate for Payer: Qualcare PPO/HMO/WC	$37.20
Rate for Payer: UnitedHealthcare Commercial	$123.99

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$188,986.44

Service Code	MSDRG 008
Min. Negotiated Rate	$55,258.30
Max. Negotiated Rate	$188,986.44
Rate for Payer: Aetna Commercial	$188,986.44
Rate for Payer: Aetna Medicare Advantage	$61,160.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$145,002.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$145,002.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$58,166.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$145,002.42
Rate for Payer: Cigna Medicare Advantage	$58,166.63
Rate for Payer: Clover Medicare Advantage	$55,258.30
Rate for Payer: EmblemHealth Commercial	$174,499.89
Rate for Payer: Humana Medicare Advantage	$59,911.63
Rate for Payer: UnitedHealthcare Medicare Advantage	$58,166.63
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$61,656.63
Rate for Payer: Wellcare Medicare Advantage	$58,166.63

Know your out-of-pocket cost for care.

All Charges