Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

OT SENSORY INTEGRATION EA 15 MINS (MOD 59)

Facility

$240.00

Service Code	HCPCS 97533 GO,59
Hospital Charge Code	4690221
Hospital Revenue Code	430
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$156.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Galaxy Health Commercial	$156.00

OT SENSORY INTEGRATION EA 15 MINS (MOD 59 W KX)

Facility

$240.00

Service Code	HCPCS 97533 GO,59,KX
Hospital Charge Code	4690252
Hospital Revenue Code	430
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$193.20
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$110.40
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$180.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$180.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$88.80
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: CDPHP Commercial	$193.20
Rate for Payer: CDPHP Medicare	$88.80
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$192.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$192.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$192.00
Rate for Payer: EmblemHealth Medicaid	$192.00
Rate for Payer: EmblemHealth Medicare	$81.60
Rate for Payer: EmblemHealth Select Care	$172.80
Rate for Payer: Fidelis Medicare	$91.46
Rate for Payer: Galaxy Health Commercial	$156.00
Rate for Payer: Hamaspik Choice Medicare	$88.80
Rate for Payer: Humana Medicare	$88.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$110.40
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	$93.24
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	$88.80
Rate for Payer: WellCare Medicare	$132.00

OT SENSORY INTEGRATION EA 15 MINS (MOD 59 W KX)

Facility

$240.00

Service Code	HCPCS 97533 GO,59,KX
Hospital Charge Code	4690252
Hospital Revenue Code	430
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$156.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Galaxy Health Commercial	$156.00

OT SENSORY INTEGRATION EA 15 MINS (W/ KX)

Facility

$240.00

Service Code	HCPCS 97533 GO,KX
Hospital Charge Code	4690186
Hospital Revenue Code	430
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$156.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Galaxy Health Commercial	$156.00

OT SENSORY INTEGRATION EA 15 MINS (W/ KX)

Facility

$240.00

Service Code	HCPCS 97533 GO,KX
Hospital Charge Code	4690186
Hospital Revenue Code	430
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$193.20
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$110.40
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$180.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$180.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$88.80
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: CDPHP Commercial	$193.20
Rate for Payer: CDPHP Medicare	$88.80
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$192.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$192.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$192.00
Rate for Payer: EmblemHealth Medicaid	$192.00
Rate for Payer: EmblemHealth Medicare	$81.60
Rate for Payer: EmblemHealth Select Care	$172.80
Rate for Payer: Fidelis Medicare	$91.46
Rate for Payer: Galaxy Health Commercial	$156.00
Rate for Payer: Hamaspik Choice Medicare	$88.80
Rate for Payer: Humana Medicare	$88.80
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$110.40
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	$93.24
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	$88.80
Rate for Payer: WellCare Medicare	$132.00

OT SLCTV WND DEBRIDEM 20 CM OR <

Facility

$573.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	4690028
Hospital Revenue Code	430
Min. Negotiated Rate	$372.45
Max. Negotiated Rate	$372.45
Rate for Payer: Cash Price	$429.75
Rate for Payer: Galaxy Health Commercial	$372.45

OT SLCTV WND DEBRIDEM 20 CM OR <

Facility

$573.00

Service Code	HCPCS 97597 GO
Hospital Charge Code	4690028
Hospital Revenue Code	430
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$461.26
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$263.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$212.01
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: CDPHP Commercial	$461.26
Rate for Payer: CDPHP Medicare	$212.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$458.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$458.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$458.40
Rate for Payer: EmblemHealth Medicaid	$458.40
Rate for Payer: EmblemHealth Medicare	$194.82
Rate for Payer: EmblemHealth Select Care	$412.56
Rate for Payer: Fidelis Medicare	$218.37
Rate for Payer: Galaxy Health Commercial	$372.45
Rate for Payer: Hamaspik Choice Medicare	$212.01
Rate for Payer: Humana Medicare	$212.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$263.58
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	$222.61
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	$212.01
Rate for Payer: WellCare Medicare	$315.15

OT SLCTV WND DEBRIDEM 20 CM OR < (MOD 59)

Facility

$573.00

Service Code	HCPCS 97597 GO,59
Hospital Charge Code	4690230
Hospital Revenue Code	430
Min. Negotiated Rate	$372.45
Max. Negotiated Rate	$372.45
Rate for Payer: Cash Price	$429.75
Rate for Payer: Galaxy Health Commercial	$372.45

OT SLCTV WND DEBRIDEM 20 CM OR < (MOD 59)

Facility

$573.00

Service Code	HCPCS 97597 GO,59
Hospital Charge Code	4690230
Hospital Revenue Code	430
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$461.26
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$263.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$212.01
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: CDPHP Commercial	$461.26
Rate for Payer: CDPHP Medicare	$212.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$458.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$458.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$458.40
Rate for Payer: EmblemHealth Medicaid	$458.40
Rate for Payer: EmblemHealth Medicare	$194.82
Rate for Payer: EmblemHealth Select Care	$412.56
Rate for Payer: Fidelis Medicare	$218.37
Rate for Payer: Galaxy Health Commercial	$372.45
Rate for Payer: Hamaspik Choice Medicare	$212.01
Rate for Payer: Humana Medicare	$212.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$263.58
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	$222.61
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	$212.01
Rate for Payer: WellCare Medicare	$315.15

OT SLCTV WND DEBRIDEM 20 CM OR < (MOD 59 W KX)

Facility

$573.00

Service Code	HCPCS 97597 GO,59,KX
Hospital Charge Code	4690261
Hospital Revenue Code	430
Min. Negotiated Rate	$372.45
Max. Negotiated Rate	$372.45
Rate for Payer: Cash Price	$429.75
Rate for Payer: Galaxy Health Commercial	$372.45

OT SLCTV WND DEBRIDEM 20 CM OR < (MOD 59 W KX)

Facility

$573.00

Service Code	HCPCS 97597 GO,59,KX
Hospital Charge Code	4690261
Hospital Revenue Code	430
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$461.26
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$263.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$212.01
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: CDPHP Commercial	$461.26
Rate for Payer: CDPHP Medicare	$212.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$458.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$458.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$458.40
Rate for Payer: EmblemHealth Medicaid	$458.40
Rate for Payer: EmblemHealth Medicare	$194.82
Rate for Payer: EmblemHealth Select Care	$412.56
Rate for Payer: Fidelis Medicare	$218.37
Rate for Payer: Galaxy Health Commercial	$372.45
Rate for Payer: Hamaspik Choice Medicare	$212.01
Rate for Payer: Humana Medicare	$212.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$263.58
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	$222.61
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	$212.01
Rate for Payer: WellCare Medicare	$315.15

OT SLCTV WND DEBRIDEM 20 CM OR < (W/ KX)

Facility

$573.00

Service Code	HCPCS 97597 GO,KX
Hospital Charge Code	4690195
Hospital Revenue Code	430
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$461.26
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$263.58
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$429.75
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$212.01
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: Cash Price	$429.75
Rate for Payer: CDPHP Commercial	$461.26
Rate for Payer: CDPHP Medicare	$212.01
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$458.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$458.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$458.40
Rate for Payer: EmblemHealth Medicaid	$458.40
Rate for Payer: EmblemHealth Medicare	$194.82
Rate for Payer: EmblemHealth Select Care	$412.56
Rate for Payer: Fidelis Medicare	$218.37
Rate for Payer: Galaxy Health Commercial	$372.45
Rate for Payer: Hamaspik Choice Medicare	$212.01
Rate for Payer: Humana Medicare	$212.01
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$263.58
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	$222.61
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	$212.01
Rate for Payer: WellCare Medicare	$315.15

OT SLCTV WND DEBRIDEM 20 CM OR < (W/ KX)

Facility

$573.00

Service Code	HCPCS 97597 GO,KX
Hospital Charge Code	4690195
Hospital Revenue Code	430
Min. Negotiated Rate	$372.45
Max. Negotiated Rate	$372.45
Rate for Payer: Cash Price	$429.75
Rate for Payer: Galaxy Health Commercial	$372.45

OT THERAPEUTIC ACTIVITIES EA 15 MINS

Facility

$136.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4690017
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITIES EA 15 MINS

Facility

$136.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4690017
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

OT THERAPEUTIC ACTIVITIES EA 15 MINS (MOD 59)

Facility

$136.00

Service Code	HCPCS 97530 GO,59
Hospital Charge Code	4690220
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

OT THERAPEUTIC ACTIVITIES EA 15 MINS (MOD 59)

Facility

$136.00

Service Code	HCPCS 97530 GO,59
Hospital Charge Code	4690220
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITIES EA 15 MINS (MOD 59 W KX)

Facility

$136.00

Service Code	HCPCS 97530 GO,59,KX
Hospital Charge Code	4690251
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

OT THERAPEUTIC ACTIVITIES EA 15 MINS (MOD 59 W KX)

Facility

$136.00

Service Code	HCPCS 97530 GO,59,KX
Hospital Charge Code	4690251
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITIES EA 15 MINS (W/ KX)

Facility

$136.00

Service Code	HCPCS 97530 GO,KX
Hospital Charge Code	4690185
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

OT THERAPEUTIC ACTIVITIES EA 15 MINS (W/ KX)

Facility

$136.00

Service Code	HCPCS 97530 GO,KX
Hospital Charge Code	4690185
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITY DIR EA 15M

Facility

$136.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4650122
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

OT THERAPEUTIC ACTIVITY DIR EA 15M

Facility

$136.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4650122
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITY DIR EA 15M (MOD 59)

Facility

$136.00

Service Code	HCPCS 97530 GO,59
Hospital Charge Code	4650401
Hospital Revenue Code	430
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$102.00
Rate for Payer: Galaxy Health Commercial	$88.40

OT THERAPEUTIC ACTIVITY DIR EA 15M (MOD 59)

Facility

$136.00

Service Code	HCPCS 97530 GO,59
Hospital Charge Code	4650401
Hospital Revenue Code	430
Min. Negotiated Rate	$46.24
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$62.56
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$102.00
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$50.32
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: CDPHP Commercial	$109.48
Rate for Payer: CDPHP Medicare	$50.32
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$108.80
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$108.80
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$108.80
Rate for Payer: EmblemHealth Medicaid	$108.80
Rate for Payer: EmblemHealth Medicare	$46.24
Rate for Payer: EmblemHealth Select Care	$97.92
Rate for Payer: Fidelis Medicare	$51.83
Rate for Payer: Galaxy Health Commercial	$88.40
Rate for Payer: Hamaspik Choice Medicare	$50.32
Rate for Payer: Humana Medicare	$50.32
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$62.56
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	$52.84
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	$50.32
Rate for Payer: WellCare Medicare	$74.80

Know your out-of-pocket cost for care.

All Charges