Heights University Hospital

All Charges

Charge

Type

Setting

Price

BREATH ALCOHOL CONFIRMATION

Facility

$80.00

Service Code	HCPCS 82075
Hospital Charge Code	3000349
Hospital Revenue Code	307
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00

BREATH ALCOHOL SCREENING

Facility

$80.00

Service Code	HCPCS 82075
Hospital Charge Code	3000348
Hospital Revenue Code	307
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00

BREATH ALCOHOL SCREENING

Facility

$80.00

Service Code	HCPCS 82075
Hospital Charge Code	3000348
Hospital Revenue Code	307
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$114.00
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: Aetna Commercial	$97.20
Rate for Payer: Aetna Medicare Advantage	$30.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$109.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$109.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$30.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$109.92
Rate for Payer: Cigna Commercial	$30.00
Rate for Payer: Cigna Medicare Advantage	$15.00
Rate for Payer: Clover Medicare Advantage	$28.50
Rate for Payer: EmblemHealth Commercial	$90.00
Rate for Payer: Humana Medicare Advantage	$30.90
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.00
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$31.80
Rate for Payer: Wellcare Medicare Advantage	$30.00

BREATH HYDROGEN TEST***

Facility

$328.00

Service Code	HCPCS 911065
Hospital Charge Code	2300887
Hospital Revenue Code	759
Min. Negotiated Rate	$42.64
Max. Negotiated Rate	$164.00
Rate for Payer: Aetna Commercial	$98.40
Rate for Payer: Aetna Medicare Advantage	$98.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$83.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$83.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$83.64
Rate for Payer: Cigna Commercial	$164.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.64
Rate for Payer: Qualcare PPO/HMO/WC	$49.20

BREATH HYDROGEN TEST***

Facility

$328.00

Service Code	HCPCS 911065
Hospital Charge Code	2300887
Hospital Revenue Code	759
Min. Negotiated Rate	$49.20
Max. Negotiated Rate	$49.20
Rate for Payer: Qualcare PPO/HMO/WC	$49.20

BREATHING AIR E TANK 22 CU

Facility

$44.20

Hospital Charge Code	270657886
Hospital Revenue Code	270
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$22.10
Rate for Payer: Aetna Commercial	$13.26
Rate for Payer: Aetna Medicare Advantage	$13.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.27
Rate for Payer: Cigna Commercial	$22.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.75
Rate for Payer: Oxford Commercial	$22.10
Rate for Payer: Qualcare PPO/HMO/WC	$6.63
Rate for Payer: UnitedHealthcare Commercial	$22.10

BREATHING AIR E TANK 22 CU

Facility

$44.20

Hospital Charge Code	270657886
Hospital Revenue Code	270
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$6.63
Rate for Payer: Qualcare PPO/HMO/WC	$6.63

BREATHING CIRCUIT MODIFIED

Facility

$59.00

Hospital Charge Code	270331542
Hospital Revenue Code	272
Min. Negotiated Rate	$7.67
Max. Negotiated Rate	$29.50
Rate for Payer: Aetna Commercial	$17.70
Rate for Payer: Aetna Medicare Advantage	$17.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.04
Rate for Payer: Cigna Commercial	$29.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.67
Rate for Payer: Oxford Commercial	$29.50
Rate for Payer: Qualcare PPO/HMO/WC	$8.85
Rate for Payer: UnitedHealthcare Commercial	$29.50

BREATHING CIRCUIT MODIFIED

Facility

$59.00

Hospital Charge Code	270331542
Hospital Revenue Code	272
Min. Negotiated Rate	$8.85
Max. Negotiated Rate	$8.85
Rate for Payer: Qualcare PPO/HMO/WC	$8.85

BREO ELLIPTA 100 MCG

Facility

$37.72

Service Code	NDC 173085914
Hospital Charge Code	606390199
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$18.86
Rate for Payer: Aetna Commercial	$11.32
Rate for Payer: Aetna Medicare Advantage	$11.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.62
Rate for Payer: Cigna Commercial	$18.86
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.90
Rate for Payer: Oxford Commercial	$18.86
Rate for Payer: Qualcare PPO/HMO/WC	$5.66
Rate for Payer: UnitedHealthcare Commercial	$18.86

BREO ELLIPTA 100 MCG

Facility

$37.72

Service Code	NDC 173085914
Hospital Charge Code	606390199
Hospital Revenue Code	250
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$5.66
Rate for Payer: Qualcare PPO/HMO/WC	$5.66

BREO ELLIPTA 200 MCG

Facility

$37.72

Service Code	NDC 173088214
Hospital Charge Code	606390200
Hospital Revenue Code	250
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$5.66
Rate for Payer: Qualcare PPO/HMO/WC	$5.66

BREO ELLIPTA 200 MCG

Facility

$37.72

Service Code	NDC 173088214
Hospital Charge Code	606390200
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$18.86
Rate for Payer: Aetna Commercial	$11.32
Rate for Payer: Aetna Medicare Advantage	$11.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.62
Rate for Payer: Cigna Commercial	$18.86
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.90
Rate for Payer: Oxford Commercial	$18.86
Rate for Payer: Qualcare PPO/HMO/WC	$5.66
Rate for Payer: UnitedHealthcare Commercial	$18.86

BRETHAIRE/0.2MG/7.5ML

Facility

$101.00

Hospital Charge Code	60632575
Hospital Revenue Code	250
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$15.15
Rate for Payer: Qualcare PPO/HMO/WC	$15.15

BRETHAIRE/0.2MG/7.5ML

Facility

$101.00

Hospital Charge Code	60632575
Hospital Revenue Code	250
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$50.50
Rate for Payer: Aetna Commercial	$30.30
Rate for Payer: Aetna Medicare Advantage	$30.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$25.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$25.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$25.75
Rate for Payer: Cigna Commercial	$50.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.13
Rate for Payer: Oxford Commercial	$50.50
Rate for Payer: Qualcare PPO/HMO/WC	$15.15
Rate for Payer: UnitedHealthcare Commercial	$50.50

BRETHINE 1MG

Facility

$15.40

Hospital Charge Code	6008106
Hospital Revenue Code	252
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

BRETHINE 1MG

Facility

$15.40

Hospital Charge Code	6008106
Hospital Revenue Code	252
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$2.31
Rate for Payer: Qualcare PPO/HMO/WC	$2.31

BRETHINE/1MG/1ML

Facility

$12.00

Hospital Charge Code	60632577
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna Medicare Advantage	$3.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.06
Rate for Payer: Cigna Commercial	$6.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.56
Rate for Payer: Oxford Commercial	$6.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.80
Rate for Payer: UnitedHealthcare Commercial	$6.00

BRETHINE/1MG/1ML

Facility

$12.00

Hospital Charge Code	60632577
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$1.80
Rate for Payer: Qualcare PPO/HMO/WC	$1.80

BRETHINE/2.5MG/TAB

Facility

$4.00

Hospital Charge Code	60632579
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

BRETHINE/2.5MG/TAB

Facility

$4.00

Hospital Charge Code	60632579
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

BRETHINE/5MG/TAB

Facility

$3.00

Hospital Charge Code	60632580
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

BRETHINE/5MG/TAB

Facility

$4.00

Hospital Charge Code	60632576
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

BRETHINE/5MG/TAB

Facility

$44.56

Service Code	NDC 527131101
Hospital Charge Code	60632578
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$6.68
Rate for Payer: Qualcare PPO/HMO/WC	$6.68

BRETHINE/5MG/TAB

Facility

$4.00

Hospital Charge Code	60632576
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

Know your out-of-pocket cost for care.

All Charges