Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

OT COGN SKILL DEVELOP EA 15 MN

Facility

$116.85

Service Code	HCPCS G0515GO
Hospital Charge Code	9100240
Hospital Revenue Code	430
Min. Negotiated Rate	$17.53
Max. Negotiated Rate	$17.53
Rate for Payer: Qualcare PPO/HMO/WC	$17.53

OT COG SKILLS DEVEL 15MIN

Facility

$141.00

Service Code	HCPCS G0515GO
Hospital Charge Code	74203059
Hospital Revenue Code	430
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$53.58
Rate for Payer: Aetna Medicare Advantage	$42.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$35.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$35.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$35.95
Rate for Payer: Cigna Commercial	$70.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.30
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.15
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$3.40
Rate for Payer: Wellpoint Medicaid Managed Care	$3.74

OT COG SKILLS DEVEL 15MIN

Facility

$141.00

Service Code	HCPCS G0515GO
Hospital Charge Code	74203059
Hospital Revenue Code	430
Min. Negotiated Rate	$21.15
Max. Negotiated Rate	$21.15
Rate for Payer: Qualcare PPO/HMO/WC	$21.15

OT COLD/HEAT APPLICATION

Facility

$0.01

Service Code	HCPCS 97010GO
Hospital Charge Code	74203025
Hospital Revenue Code	430
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

OT COLD/HEAT APPLICATION

Facility

$0.01

Service Code	HCPCS 97010GO
Hospital Charge Code	74203025
Hospital Revenue Code	430
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$0.00
Rate for Payer: Aetna Medicare Advantage	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.00
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.00
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.00
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$0.00
Rate for Payer: Wellpoint Medicaid Managed Care	$0.00

OT COMMUNTY/WORK TRAING EA 15M

Facility

$102.40

Service Code	HCPCS 97537GO
Hospital Charge Code	9100130
Hospital Revenue Code	430
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$15.36
Rate for Payer: Qualcare PPO/HMO/WC	$15.36

OT COMMUNTY/WORK TRAING EA 15M

Facility

$102.40

Service Code	HCPCS 97537GO
Hospital Charge Code	9100130
Hospital Revenue Code	430
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$38.91
Rate for Payer: Aetna Medicare Advantage	$30.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.11
Rate for Payer: Cigna Commercial	$51.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$30.72
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.36
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$2.47
Rate for Payer: Wellpoint Medicaid Managed Care	$2.71

OT CONTRAST BATH EACH 15 MIN

Facility

$106.00

Service Code	HCPCS 97034GO
Hospital Charge Code	1008180
Hospital Revenue Code	430
Min. Negotiated Rate	$15.90
Max. Negotiated Rate	$15.90
Rate for Payer: Qualcare PPO/HMO/WC	$15.90

OT CONTRAST BATH EACH 15 MIN

Facility

$106.00

Service Code	HCPCS 97034GO
Hospital Charge Code	1008180
Hospital Revenue Code	430
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$40.28
Rate for Payer: Aetna Medicare Advantage	$31.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.03
Rate for Payer: Cigna Commercial	$53.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.80
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.90
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$2.55
Rate for Payer: Wellpoint Medicaid Managed Care	$2.81

OT CONTRAST BATHS 15MIN

Facility

$106.00

Service Code	HCPCS 97034GO
Hospital Charge Code	74203039
Hospital Revenue Code	430
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$40.28
Rate for Payer: Aetna Medicare Advantage	$31.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.03
Rate for Payer: Cigna Commercial	$53.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.80
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.90
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$2.55
Rate for Payer: Wellpoint Medicaid Managed Care	$2.81

OT CONTRAST BATHS 15MIN

Facility

$106.00

Service Code	HCPCS 97034GO
Hospital Charge Code	74203039
Hospital Revenue Code	430
Min. Negotiated Rate	$15.90
Max. Negotiated Rate	$15.90
Rate for Payer: Qualcare PPO/HMO/WC	$15.90

OT CUSTOM SPLINT - LEVEL 1

Facility

$77.65

Hospital Charge Code	9100010
Hospital Revenue Code	274
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$38.83
Rate for Payer: Aetna Commercial	$29.51
Rate for Payer: Aetna Medicare Advantage	$23.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.80
Rate for Payer: Cigna Commercial	$38.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$17.08
Rate for Payer: Qualcare PPO/HMO/WC	$11.65
Rate for Payer: UnitedHealthcare Community & State	$1.87
Rate for Payer: Wellpoint Medicaid Managed Care	$2.06

OT CUSTOM SPLINT - LEVEL 1

Facility

$77.65

Hospital Charge Code	9100010
Hospital Revenue Code	274
Min. Negotiated Rate	$11.65
Max. Negotiated Rate	$18.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$15.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$17.08
Rate for Payer: Qualcare PPO/HMO/WC	$11.65

OT CUSTOM SPLINT - LEVEL 2

Facility

$153.65

Hospital Charge Code	9100011
Hospital Revenue Code	274
Min. Negotiated Rate	$3.70
Max. Negotiated Rate	$76.83
Rate for Payer: Aetna Commercial	$58.39
Rate for Payer: Aetna Medicare Advantage	$46.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$30.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$76.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.18
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$33.80
Rate for Payer: Qualcare PPO/HMO/WC	$23.05
Rate for Payer: UnitedHealthcare Community & State	$3.70
Rate for Payer: Wellpoint Medicaid Managed Care	$4.07

OT CUSTOM SPLINT - LEVEL 2

Facility

$153.65

Hospital Charge Code	9100011
Hospital Revenue Code	274
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$37.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$30.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.18
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$33.80
Rate for Payer: Qualcare PPO/HMO/WC	$23.05

OT CUSTOM SPLINT - LEVEL 3

Facility

$192.85

Hospital Charge Code	9100012
Hospital Revenue Code	270
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$96.42
Rate for Payer: Aetna Commercial	$73.28
Rate for Payer: Aetna Medicare Advantage	$57.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.18
Rate for Payer: Cigna Commercial	$96.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.85
Rate for Payer: Oxford Commercial	$38.57
Rate for Payer: Qualcare PPO/HMO/WC	$28.93
Rate for Payer: UnitedHealthcare Commercial	$38.57
Rate for Payer: UnitedHealthcare Community & State	$4.65
Rate for Payer: Wellpoint Medicaid Managed Care	$5.11

OT CUSTOM SPLINT - LEVEL 3

Facility

$192.85

Hospital Charge Code	9100012
Hospital Revenue Code	270
Min. Negotiated Rate	$28.93
Max. Negotiated Rate	$28.93
Rate for Payer: Qualcare PPO/HMO/WC	$28.93

OT CUSTOM SPLINT - LEVEL 4

Facility

$307.25

Hospital Charge Code	9100013
Hospital Revenue Code	274
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$153.62
Rate for Payer: Aetna Commercial	$116.75
Rate for Payer: Aetna Medicare Advantage	$92.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$78.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$78.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$78.35
Rate for Payer: Cigna Commercial	$153.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.35
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$67.59
Rate for Payer: Qualcare PPO/HMO/WC	$46.09
Rate for Payer: UnitedHealthcare Community & State	$7.40
Rate for Payer: Wellpoint Medicaid Managed Care	$8.14

OT CUSTOM SPLINT - LEVEL 4

Facility

$307.25

Hospital Charge Code	9100013
Hospital Revenue Code	274
Min. Negotiated Rate	$46.09
Max. Negotiated Rate	$74.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$61.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$74.35
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$67.59
Rate for Payer: Qualcare PPO/HMO/WC	$46.09

OT CYBEX EVALUATION EA 15 MIN

Facility

$113.30

Service Code	HCPCS 97750GO
Hospital Charge Code	9100044
Hospital Revenue Code	430
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$17.00
Rate for Payer: Qualcare PPO/HMO/WC	$17.00

OT CYBEX EVALUATION EA 15 MIN

Facility

$113.30

Service Code	HCPCS 97750GO
Hospital Charge Code	9100044
Hospital Revenue Code	430
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$43.05
Rate for Payer: Aetna Medicare Advantage	$33.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$28.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$28.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$28.89
Rate for Payer: Cigna Commercial	$56.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.99
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$17.00
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$2.73
Rate for Payer: Wellpoint Medicaid Managed Care	$3.00

OT CYBEX TREATMENT EA 15 MIN**

Facility

$45.00

Service Code	HCPCS 97110GO
Hospital Charge Code	9100042
Hospital Revenue Code	430
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$6.75
Rate for Payer: Qualcare PPO/HMO/WC	$6.75

OT CYBEX TREATMENT EA 15 MIN**

Facility

$45.00

Service Code	HCPCS 97110GO
Hospital Charge Code	9100042
Hospital Revenue Code	430
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare Advantage	$13.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.47
Rate for Payer: Cigna Commercial	$22.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.50
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.75
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$1.08
Rate for Payer: Wellpoint Medicaid Managed Care	$1.19

OT DEVELOPMENTAL TESTING: EXTE

Facility

$256.65

Service Code	HCPCS 96111
Hospital Charge Code	9100210
Hospital Revenue Code	918
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$3,081.00
Rate for Payer: Aetna Commercial	$97.53
Rate for Payer: Aetna Medicare Advantage	$77.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$65.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$65.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$65.45
Rate for Payer: Cigna Commercial	$128.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$77.00
Rate for Payer: Oxford Commercial	$1,757.00
Rate for Payer: Qualcare PPO/HMO/WC	$38.50
Rate for Payer: UnitedHealthcare Commercial	$3,081.00
Rate for Payer: UnitedHealthcare Community & State	$6.19
Rate for Payer: Wellpoint Medicaid Managed Care	$6.80

OT DEVELOPMENTAL TESTING: EXTE

Facility

$256.65

Service Code	HCPCS 96111
Hospital Charge Code	9100210
Hospital Revenue Code	918
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$38.50
Rate for Payer: Qualcare PPO/HMO/WC	$38.50

Know your out-of-pocket cost for care.

All Charges