|
OT EVAL HIGH COMPLEX 60 MIN (MOD 59 W KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,59,KX
|
| Hospital Charge Code |
4690236
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL HIGH COMPLEX 60 MIN (W/ KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,KX
|
| Hospital Charge Code |
4690170
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL HIGH COMPLEX 60 MIN (W/ KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,KX
|
| Hospital Charge Code |
4690170
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL LOW COMPLEX 30 MIN
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO
|
| Hospital Charge Code |
4690000
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL LOW COMPLEX 30 MIN
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO
|
| Hospital Charge Code |
4690000
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL LOW COMPLEX 30 MIN (MOD 59)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,59
|
| Hospital Charge Code |
4690203
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL LOW COMPLEX 30 MIN (MOD 59)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,59
|
| Hospital Charge Code |
4690203
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL LOW COMPLEX 30 MIN (MOD 59 W KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,59,KX
|
| Hospital Charge Code |
4690234
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL LOW COMPLEX 30 MIN (MOD 59 W KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,59,KX
|
| Hospital Charge Code |
4690234
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL LOW COMPLEX 30 MIN (W/ KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,KX
|
| Hospital Charge Code |
4690168
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL LOW COMPLEX 30 MIN (W/ KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,KX
|
| Hospital Charge Code |
4690168
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL MOD COMPLEX 45 MIN
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO
|
| Hospital Charge Code |
4690001
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL MOD COMPLEX 45 MIN
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO
|
| Hospital Charge Code |
4690001
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL MOD COMPLEX 45 MIN (MOD 59)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,59
|
| Hospital Charge Code |
4690204
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL MOD COMPLEX 45 MIN (MOD 59)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,59
|
| Hospital Charge Code |
4690204
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL MOD COMPLEX 45 MIN (MOD 59 W KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,59,KX
|
| Hospital Charge Code |
4690235
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL MOD COMPLEX 45 MIN (MOD 59 W KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,59,KX
|
| Hospital Charge Code |
4690235
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT EVAL MOD COMPLEX 45 MIN (W/ KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,KX
|
| Hospital Charge Code |
4690169
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$293.82 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$273.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.05
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: CDPHP Commercial |
$293.82
|
| Rate for Payer: CDPHP Medicare |
$135.05
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.00
|
| Rate for Payer: EmblemHealth Medicaid |
$292.00
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$139.10
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.05
|
| Rate for Payer: Humana Medicare |
$135.05
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$141.80
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL MOD COMPLEX 45 MIN (W/ KX)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97166 GO,KX
|
| Hospital Charge Code |
4690169
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$237.25 |
| Max. Negotiated Rate |
$237.25 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO
|
| Hospital Charge Code |
4690014
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$45.51
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: CDPHP Commercial |
$99.02
|
| Rate for Payer: CDPHP Medicare |
$45.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$98.40
|
| Rate for Payer: EmblemHealth Medicaid |
$98.40
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$46.88
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$45.51
|
| Rate for Payer: Humana Medicare |
$45.51
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$47.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$45.51
|
| Rate for Payer: WellCare Medicare |
$67.65
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO
|
| Hospital Charge Code |
4690014
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.95 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (MOD 59)
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,59
|
| Hospital Charge Code |
4690217
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.95 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (MOD 59)
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,59
|
| Hospital Charge Code |
4690217
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$45.51
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: CDPHP Commercial |
$99.02
|
| Rate for Payer: CDPHP Medicare |
$45.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$98.40
|
| Rate for Payer: EmblemHealth Medicaid |
$98.40
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$46.88
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$45.51
|
| Rate for Payer: Humana Medicare |
$45.51
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$47.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$45.51
|
| Rate for Payer: WellCare Medicare |
$67.65
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,59,KX
|
| Hospital Charge Code |
4690248
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$92.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$45.51
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: CDPHP Commercial |
$99.02
|
| Rate for Payer: CDPHP Medicare |
$45.51
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$98.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$98.40
|
| Rate for Payer: EmblemHealth Medicaid |
$98.40
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$46.88
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Hamaspik Choice Medicare |
$45.51
|
| Rate for Payer: Humana Medicare |
$45.51
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$47.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$45.51
|
| Rate for Payer: WellCare Medicare |
$67.65
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,59,KX
|
| Hospital Charge Code |
4690248
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.95 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
|
