Heights University Hospital

All Charges

Charge

Type

Setting

Price

OT ELEC STIM MANUAL EA 15 MIN

Facility

$116.85

Service Code	HCPCS 97032GO
Hospital Charge Code	9100050
Hospital Revenue Code	430
Min. Negotiated Rate	$17.53
Max. Negotiated Rate	$17.53
Rate for Payer: Qualcare PPO/HMO/WC	$17.53

OT ELEC STIM UNATTENDED

Facility

$153.00

Service Code	HCPCS G0283GO
Hospital Charge Code	74203085
Hospital Revenue Code	430
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$22.95
Rate for Payer: Qualcare PPO/HMO/WC	$22.95

OT ELEC STIM UNATTENDED

Facility

$153.00

Service Code	HCPCS G0283GO
Hospital Charge Code	74203085
Hospital Revenue Code	430
Min. Negotiated Rate	$19.89
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: Aetna Medicare Advantage	$45.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.02
Rate for Payer: Cigna Commercial	$76.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.89
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.95
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVAL HIGH COMPLEX 60 MIN

Facility

$2,400.00

Service Code	HCPCS 97167GO
Hospital Charge Code	74203124
Hospital Revenue Code	434
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$720.00
Rate for Payer: Aetna Medicare Advantage	$720.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$612.00
Rate for Payer: Cigna Commercial	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$312.00
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVAL HIGH COMPLEX 60 MIN

Facility

$2,400.00

Service Code	HCPCS 97167GO
Hospital Charge Code	74203124
Hospital Revenue Code	434
Min. Negotiated Rate	$360.00
Max. Negotiated Rate	$360.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00

OT EVAL LOW COMPLEX 30 MIN

Facility

$2,400.00

Service Code	HCPCS 97165GO
Hospital Charge Code	74203122
Hospital Revenue Code	434
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$720.00
Rate for Payer: Aetna Medicare Advantage	$720.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$612.00
Rate for Payer: Cigna Commercial	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$312.00
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVAL LOW COMPLEX 30 MIN

Facility

$2,400.00

Service Code	HCPCS 97165GO
Hospital Charge Code	74203122
Hospital Revenue Code	434
Min. Negotiated Rate	$360.00
Max. Negotiated Rate	$360.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00

OT EVAL MOD COMPLEX 45 MIN

Facility

$2,400.00

Service Code	HCPCS 97166GO
Hospital Charge Code	74203126
Hospital Revenue Code	434
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$720.00
Rate for Payer: Aetna Medicare Advantage	$720.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$612.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$612.00
Rate for Payer: Cigna Commercial	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$312.00
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVAL MOD COMPLEX 45 MIN

Facility

$2,400.00

Service Code	HCPCS 97166GO
Hospital Charge Code	74203126
Hospital Revenue Code	434
Min. Negotiated Rate	$360.00
Max. Negotiated Rate	$360.00
Rate for Payer: Qualcare PPO/HMO/WC	$360.00

OT EVALUATION

Facility

$332.85

Service Code	HCPCS 97003GO
Hospital Charge Code	9000431
Hospital Revenue Code	434
Min. Negotiated Rate	$43.27
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$99.86
Rate for Payer: Aetna Medicare Advantage	$99.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$84.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$84.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$84.88
Rate for Payer: Cigna Commercial	$166.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.27
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$49.93
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVALUATION

Facility

$523.00

Service Code	HCPCS 97003GO
Hospital Charge Code	74203021
Hospital Revenue Code	434
Min. Negotiated Rate	$67.99
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$156.90
Rate for Payer: Aetna Medicare Advantage	$156.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$133.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$133.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$133.37
Rate for Payer: Cigna Commercial	$261.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$67.99
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$78.45
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVALUATION

Facility

$523.00

Service Code	HCPCS 97003GO
Hospital Charge Code	74203021
Hospital Revenue Code	434
Min. Negotiated Rate	$78.45
Max. Negotiated Rate	$78.45
Rate for Payer: Qualcare PPO/HMO/WC	$78.45

OT EVALUATION

Facility

$332.85

Service Code	HCPCS 97003GO
Hospital Charge Code	9000431
Hospital Revenue Code	434
Min. Negotiated Rate	$49.93
Max. Negotiated Rate	$49.93
Rate for Payer: Qualcare PPO/HMO/WC	$49.93

OT EVALUATION****

Facility

$125.00

Service Code	HCPCS 97003GO
Hospital Charge Code	9100046
Hospital Revenue Code	434
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$37.50
Rate for Payer: Aetna Medicare Advantage	$37.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$31.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$31.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$31.88
Rate for Payer: Cigna Commercial	$62.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16.25
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.75
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT EVALUATION****

Facility

$125.00

Service Code	HCPCS 97003GO
Hospital Charge Code	9100046
Hospital Revenue Code	434
Min. Negotiated Rate	$18.75
Max. Negotiated Rate	$18.75
Rate for Payer: Qualcare PPO/HMO/WC	$18.75

OT:FAMILY EDUCATION/CONF 15 MI

Facility

$60.00

Service Code	HCPCS 97535GO
Hospital Charge Code	1008315
Hospital Revenue Code	430
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00

OT:FAMILY EDUCATION/CONF 15 MI

Facility

$60.00

Service Code	HCPCS 97535GO
Hospital Charge Code	1008315
Hospital Revenue Code	430
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: Aetna Medicare Advantage	$18.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.30
Rate for Payer: Cigna Commercial	$30.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.80
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.00
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT - FINGER SPLINT DYNAM - LT

Facility

$0.01

Service Code	HCPCS 29131GO
Hospital Charge Code	74203123
Hospital Revenue Code	430
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

OT - FINGER SPLINT DYNAM - LT

Facility

$0.01

Service Code	HCPCS 29131GO
Hospital Charge Code	74203123
Hospital Revenue Code	430
Max. Negotiated Rate	$686.00
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	$90.00
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	$686.00

OT FINGER SPLINT DYNAM RT

Facility

$351.00

Service Code	HCPCS 29131GO
Hospital Charge Code	74203015
Hospital Revenue Code	430
Min. Negotiated Rate	$45.63
Max. Negotiated Rate	$686.00
Rate for Payer: Aetna Commercial	$105.30
Rate for Payer: Aetna Medicare Advantage	$105.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$89.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$89.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$90.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$89.50
Rate for Payer: Cigna Commercial	$175.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.63
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$52.65
Rate for Payer: UnitedHealthcare Commercial	$686.00

OT FINGER SPLINT DYNAM RT

Facility

$351.00

Service Code	HCPCS 29131GO
Hospital Charge Code	74203015
Hospital Revenue Code	430
Min. Negotiated Rate	$52.65
Max. Negotiated Rate	$52.65
Rate for Payer: Qualcare PPO/HMO/WC	$52.65

OT-FINGER SPLINT STAT - BIL

Facility

$0.01

Service Code	HCPCS 29130GO
Hospital Charge Code	74203125
Hospital Revenue Code	430
Max. Negotiated Rate	$686.00
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	$90.00
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	$686.00

OT-FINGER SPLINT STAT - BIL

Facility

$0.01

Service Code	HCPCS 29130GO
Hospital Charge Code	74203125
Hospital Revenue Code	430
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

OT-FINGER SPLINT STATI -LT

Facility

$0.01

Service Code	HCPCS 29130GO
Hospital Charge Code	74203127
Hospital Revenue Code	430
Max. Negotiated Rate	$686.00
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	$90.00
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	$686.00

OT-FINGER SPLINT STATI -LT

Facility

$0.01

Service Code	HCPCS 29130GO
Hospital Charge Code	74203127
Hospital Revenue Code	430
Rate for Payer: Qualcare PPO/HMO/WC	$0.00

Know your out-of-pocket cost for care.

All Charges