Heights University Hospital

All Charges

Charge

Type

Setting

Price

TRIMED IV FILTER **********

Facility

$8.00

Hospital Charge Code	7000805
Hospital Revenue Code	279
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$1.20

TRIMETHAPHAN CAMS INJ 50MG/ML

Facility

$336.00

Service Code	HCPCS J0400
Hospital Charge Code	6005516
Hospital Revenue Code	250
Min. Negotiated Rate	$43.68
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna Commercial	$100.80
Rate for Payer: Aetna Medicare Advantage	$100.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$85.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$85.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$85.68
Rate for Payer: Cigna Commercial	$168.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.68
Rate for Payer: Oxford Commercial	$168.00
Rate for Payer: Qualcare PPO/HMO/WC	$50.40
Rate for Payer: UnitedHealthcare Commercial	$168.00

TRIMETHAPHAN CAMS INJ 50MG/ML

Facility

$336.00

Service Code	HCPCS J0400
Hospital Charge Code	6005516
Hospital Revenue Code	250
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$50.40
Rate for Payer: Qualcare PPO/HMO/WC	$50.40

TRIMETHOBENZAMIDE -100 MG SUPP

Facility

$13.65

Hospital Charge Code	60628150
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.05
Rate for Payer: Qualcare PPO/HMO/WC	$2.05

TRIMETHOBENZAMIDE -100 MG SUPP

Facility

$13.65

Hospital Charge Code	60628150
Hospital Revenue Code	250
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$6.83
Rate for Payer: Aetna Commercial	$4.09
Rate for Payer: Aetna Medicare Advantage	$4.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.48
Rate for Payer: Cigna Commercial	$6.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.77
Rate for Payer: Oxford Commercial	$6.83
Rate for Payer: Qualcare PPO/HMO/WC	$2.05
Rate for Payer: UnitedHealthcare Commercial	$6.83

TRIMETHOBENZAMIDE -200 MG SUPP

Facility

$3.85

Hospital Charge Code	60628151
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.93
Rate for Payer: Aetna Commercial	$1.16
Rate for Payer: Aetna Medicare Advantage	$1.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.98
Rate for Payer: Cigna Commercial	$1.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.50
Rate for Payer: Oxford Commercial	$1.93
Rate for Payer: Qualcare PPO/HMO/WC	$0.58
Rate for Payer: UnitedHealthcare Commercial	$1.93

TRIMETHOBENZAMIDE -200 MG SUPP

Facility

$3.85

Hospital Charge Code	60628151
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: Qualcare PPO/HMO/WC	$0.58

TRIMETHOBENZAMIDE 250 MG CAP

Facility

$4.85

Hospital Charge Code	60628153
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.73

TRIMETHOBENZAMIDE 250 MG CAP

Facility

$4.85

Hospital Charge Code	60628153
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$1.46
Rate for Payer: Aetna Medicare Advantage	$1.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.24
Rate for Payer: Cigna Commercial	$2.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.63
Rate for Payer: Oxford Commercial	$2.42
Rate for Payer: Qualcare PPO/HMO/WC	$0.73
Rate for Payer: UnitedHealthcare Commercial	$2.42

TRIMETHOBENZAMIDE250MG UD

Facility

$3.00

Hospital Charge Code	60634026
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

TRIMETHOBENZAMIDE250MG UD

Facility

$3.00

Hospital Charge Code	60634026
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

TRIMETHOBENZAMIDE 300 MG CAP

Facility

$21.51

Service Code	HCPCS Q0173
Hospital Charge Code	60629360
Hospital Revenue Code	636
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$5.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.21
Rate for Payer: Qualcare PPO/HMO/WC	$3.23

TRIMETHOBENZAMIDE 300 MG CAP

Facility

$21.51

Service Code	HCPCS Q0173
Hospital Charge Code	60629360
Hospital Revenue Code	636
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$10.76
Rate for Payer: Aetna Commercial	$6.45
Rate for Payer: Aetna Medicare Advantage	$6.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.49
Rate for Payer: Cigna Commercial	$10.76
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.21
Rate for Payer: Qualcare PPO/HMO/WC	$3.23

TRIMETHOBENZAMIDE CAP 100MG

Facility

$4.85

Hospital Charge Code	60628149
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Qualcare PPO/HMO/WC	$0.73

TRIMETHOBENZAMIDE CAP 100MG

Facility

$4.85

Hospital Charge Code	60628149
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$1.46
Rate for Payer: Aetna Medicare Advantage	$1.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.24
Rate for Payer: Cigna Commercial	$2.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.63
Rate for Payer: Oxford Commercial	$2.42
Rate for Payer: Qualcare PPO/HMO/WC	$0.73
Rate for Payer: UnitedHealthcare Commercial	$2.42

TRIMETHOBENZAMIDE INJ

Facility

$14.00

Service Code	HCPCS K0240
Hospital Charge Code	6006340
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$2.10
Rate for Payer: Qualcare PPO/HMO/WC	$2.10

TRIMETHOBENZAMIDE INJ

Facility

$14.00

Service Code	HCPCS K0240
Hospital Charge Code	6006340
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$4.20
Rate for Payer: Aetna Medicare Advantage	$4.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.57
Rate for Payer: Cigna Commercial	$7.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.82
Rate for Payer: Oxford Commercial	$7.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.10
Rate for Payer: UnitedHealthcare Commercial	$7.00

TRIMETHOBENZAMIDE INJ200MG/2ML

Facility

$47.64

Service Code	HCPCS J3250
Hospital Charge Code	60628152
Hospital Revenue Code	636
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$11.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.53
Rate for Payer: Qualcare PPO/HMO/WC	$7.15

TRIMETHOBENZAMIDE INJ200MG/2ML

Facility

$47.64

Service Code	HCPCS J3250
Hospital Charge Code	60628152
Hospital Revenue Code	636
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$57.22
Rate for Payer: Aetna Commercial	$14.29
Rate for Payer: Aetna Medicare Advantage	$14.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12.15
Rate for Payer: Cigna Commercial	$57.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.53
Rate for Payer: Qualcare PPO/HMO/WC	$7.15

TRIMETHOBENZAMIDE SUPP 200MG

Facility

$3.20

Hospital Charge Code	6022891
Hospital Revenue Code	251
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

TRIMETHOBENZAMIDE SUPP 200MG

Facility

$3.20

Hospital Charge Code	6022891
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

TRIMETHOBENZAMIDE SUPP 200MG

Facility

$3.20

Hospital Charge Code	6022883
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

TRIMETHOBENZAMIDE SUPP 200MG

Facility

$3.20

Hospital Charge Code	6022883
Hospital Revenue Code	251
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

TRIMETHOBENZAMIOC SUPP 100MG

Facility

$3.20

Hospital Charge Code	6023428
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

TRIMETHOBENZAMIOC SUPP 100MG

Facility

$3.20

Hospital Charge Code	6023428
Hospital Revenue Code	251
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

Know your out-of-pocket cost for care.

All Charges