Heights University Hospital

All Charges

Charge

Type

Setting

Price

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	411075726L
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-LT

Facility

$8,514.00

Service Code	HCPCS 75726LT
Hospital Charge Code	7412004
Hospital Revenue Code	323
Min. Negotiated Rate	$1,277.10
Max. Negotiated Rate	$1,277.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	366875726L
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-LT

Facility

$8,514.00

Service Code	HCPCS 75726LT
Hospital Charge Code	7412004
Hospital Revenue Code	323
Min. Negotiated Rate	$1,106.82
Max. Negotiated Rate	$4,257.00
Rate for Payer: Aetna Commercial	$2,554.20
Rate for Payer: Aetna Medicare Advantage	$2,554.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,171.07
Rate for Payer: Cigna Commercial	$4,257.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,106.82
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	2691875
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	321075726L
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	2691875
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-LT

Facility

$25,628.45

Service Code	HCPCS 75726LT
Hospital Charge Code	411075726L
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	321075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$8,514.00

Service Code	HCPCS 75726RT
Hospital Charge Code	7412005
Hospital Revenue Code	323
Min. Negotiated Rate	$1,106.82
Max. Negotiated Rate	$4,257.00
Rate for Payer: Aetna Commercial	$2,554.20
Rate for Payer: Aetna Medicare Advantage	$2,554.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,171.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,171.07
Rate for Payer: Cigna Commercial	$4,257.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,106.82
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	366875726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	2691880
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-RT

Facility

$8,514.00

Service Code	HCPCS 75726RT
Hospital Charge Code	7412005
Hospital Revenue Code	323
Min. Negotiated Rate	$1,277.10
Max. Negotiated Rate	$1,277.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,277.10

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	321075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	411075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	411075726R
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	2691880
Hospital Revenue Code	323
Min. Negotiated Rate	$3,844.27
Max. Negotiated Rate	$3,844.27
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27

VISCERAL SELECTIVE-RT

Facility

$25,628.45

Service Code	HCPCS 75726RT
Hospital Charge Code	366875726R
Hospital Revenue Code	323
Min. Negotiated Rate	$1,311.00
Max. Negotiated Rate	$12,814.23
Rate for Payer: Aetna Commercial	$7,688.53
Rate for Payer: Aetna Medicare Advantage	$7,688.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,535.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,535.25
Rate for Payer: Cigna Commercial	$12,814.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,331.70
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,844.27
Rate for Payer: UnitedHealthcare Commercial	$1,489.00

VISCERA RETAINER MED *******

Facility

$34.00

Hospital Charge Code	1601079
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.10
Rate for Payer: Qualcare PPO/HMO/WC	$5.10

VISCERA RETAINER MED *******

Facility

$34.00

Hospital Charge Code	1601079
Hospital Revenue Code	272
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Medicare Advantage	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.67
Rate for Payer: Cigna Commercial	$17.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.42
Rate for Payer: Oxford Commercial	$17.00
Rate for Payer: Qualcare PPO/HMO/WC	$5.10
Rate for Payer: UnitedHealthcare Commercial	$17.00

VISCOAT .05ML SYRINGE (STF)

Facility

$455.00

Hospital Charge Code	270330681
Hospital Revenue Code	250
Min. Negotiated Rate	$59.15
Max. Negotiated Rate	$227.50
Rate for Payer: Aetna Commercial	$136.50
Rate for Payer: Aetna Medicare Advantage	$136.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$116.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$116.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$116.03
Rate for Payer: Cigna Commercial	$227.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$59.15
Rate for Payer: Oxford Commercial	$227.50
Rate for Payer: Qualcare PPO/HMO/WC	$68.25
Rate for Payer: UnitedHealthcare Commercial	$227.50

VISCOAT .05ML SYRINGE (STF)

Facility

$455.00

Hospital Charge Code	270330681
Hospital Revenue Code	250
Min. Negotiated Rate	$68.25
Max. Negotiated Rate	$68.25
Rate for Payer: Qualcare PPO/HMO/WC	$68.25

VISCOAT 05ML SYRINGE(STM)

Facility

$382.00

Hospital Charge Code	270332494
Hospital Revenue Code	250
Min. Negotiated Rate	$57.30
Max. Negotiated Rate	$57.30
Rate for Payer: Qualcare PPO/HMO/WC	$57.30

VISCOAT 05ML SYRINGE(STM)

Facility

$382.00

Hospital Charge Code	270332494
Hospital Revenue Code	250
Min. Negotiated Rate	$49.66
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$114.60
Rate for Payer: Aetna Medicare Advantage	$114.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$97.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$97.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$97.41
Rate for Payer: Cigna Commercial	$191.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$49.66
Rate for Payer: Oxford Commercial	$191.00
Rate for Payer: Qualcare PPO/HMO/WC	$57.30
Rate for Payer: UnitedHealthcare Commercial	$191.00

VISCOAT INJ 0.5ML

Facility

$1,228.80

Hospital Charge Code	6006811
Hospital Revenue Code	250
Min. Negotiated Rate	$159.74
Max. Negotiated Rate	$614.40
Rate for Payer: Aetna Commercial	$368.64
Rate for Payer: Aetna Medicare Advantage	$368.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$313.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$313.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$313.34
Rate for Payer: Cigna Commercial	$614.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$159.74
Rate for Payer: Oxford Commercial	$614.40
Rate for Payer: Qualcare PPO/HMO/WC	$184.32
Rate for Payer: UnitedHealthcare Commercial	$614.40

Know your out-of-pocket cost for care.

All Charges