Ellenville Regional Hospital

All Charges

Charge

Type

Setting

Price

OT THERAPEUTIC REHAB GROUP (2 OR MORE) (MOD 59 W KX)

Facility

$63.00

Service Code	HCPCS 97150 GO,59,KX
Hospital Charge Code	4690257
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT THERAPEUTIC REHAB GROUP (2 OR MORE) (W/ KX)

Facility

$63.00

Service Code	HCPCS 97150 GO,KX
Hospital Charge Code	4690191
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT THERAPEUTIC REHAB GROUP (2 OR MORE) (W/ KX)

Facility

$63.00

Service Code	HCPCS 97150 GO,KX
Hospital Charge Code	4690191
Hospital Revenue Code	430
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$28.98
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	$24.48
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	$23.31
Rate for Payer: WellCare Medicare	$34.65

OT ULTRASOUND THERAPY EA 15 MINS

Facility

$63.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	4690011
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT ULTRASOUND THERAPY EA 15 MINS

Facility

$63.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	4690011
Hospital Revenue Code	430
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$28.98
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	$24.48
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	$23.31
Rate for Payer: WellCare Medicare	$34.65

OT ULTRASOUND THERAPY EA 15 MINS (MOD 59)

Facility

$63.00

Service Code	HCPCS 97035 GO,59
Hospital Charge Code	4690214
Hospital Revenue Code	430
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$28.98
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	$24.48
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	$23.31
Rate for Payer: WellCare Medicare	$34.65

OT ULTRASOUND THERAPY EA 15 MINS (MOD 59)

Facility

$63.00

Service Code	HCPCS 97035 GO,59
Hospital Charge Code	4690214
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT ULTRASOUND THERAPY EA 15 MINS (MOD 59 W KX)

Facility

$63.00

Service Code	HCPCS 97035 GO,59,KX
Hospital Charge Code	4690245
Hospital Revenue Code	430
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$28.98
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	$24.48
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	$23.31
Rate for Payer: WellCare Medicare	$34.65

OT ULTRASOUND THERAPY EA 15 MINS (MOD 59 W KX)

Facility

$63.00

Service Code	HCPCS 97035 GO,59,KX
Hospital Charge Code	4690245
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT ULTRASOUND THERAPY EA 15 MINS (W/ KX)

Facility

$63.00

Service Code	HCPCS 97035 GO,KX
Hospital Charge Code	4690179
Hospital Revenue Code	430
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$40.95
Rate for Payer: Cash Price	$47.25
Rate for Payer: Galaxy Health Commercial	$40.95

OT ULTRASOUND THERAPY EA 15 MINS (W/ KX)

Facility

$63.00

Service Code	HCPCS 97035 GO,KX
Hospital Charge Code	4690179
Hospital Revenue Code	430
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$28.98
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$47.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$23.31
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: CDPHP Commercial	$50.72
Rate for Payer: CDPHP Medicare	$23.31
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$50.40
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$50.40
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$50.40
Rate for Payer: EmblemHealth Medicaid	$50.40
Rate for Payer: EmblemHealth Medicare	$21.42
Rate for Payer: EmblemHealth Select Care	$45.36
Rate for Payer: Fidelis Medicare	$24.01
Rate for Payer: Galaxy Health Commercial	$40.95
Rate for Payer: Hamaspik Choice Medicare	$23.31
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$28.98
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	$24.48
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	$23.31
Rate for Payer: WellCare Medicare	$34.65

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN

Facility

$115.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	4650119
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN

Facility

$115.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	4650119
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN (MOD 59)

Facility

$115.00

Service Code	HCPCS 97542 GO,59
Hospital Charge Code	4650399
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN (MOD 59)

Facility

$115.00

Service Code	HCPCS 97542 GO,59
Hospital Charge Code	4650399
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN (MOD 59 W KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,59,KX
Hospital Charge Code	4650451
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN (MOD 59 W KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,59,KX
Hospital Charge Code	4650451
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS

Facility

$115.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	4690022
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS

Facility

$115.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	4690022
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (MOD 59)

Facility

$115.00

Service Code	HCPCS 97542 GO,59
Hospital Charge Code	4690224
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (MOD 59)

Facility

$115.00

Service Code	HCPCS 97542 GO,59
Hospital Charge Code	4690224
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (MOD 59 W KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,59,KX
Hospital Charge Code	4690255
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (MOD 59 W KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,59,KX
Hospital Charge Code	4690255
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (W/ KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,KX
Hospital Charge Code	4690189
Hospital Revenue Code	430
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna of NY Commercial	$112.00
Rate for Payer: Aetna of NY Medicare	$52.90
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO	$86.25
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare	$42.55
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp	$108.00
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: Cash Price	$86.25
Rate for Payer: CDPHP Commercial	$92.58
Rate for Payer: CDPHP Medicare	$42.55
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access	$92.00
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2	$92.00
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4	$92.00
Rate for Payer: EmblemHealth Medicaid	$92.00
Rate for Payer: EmblemHealth Medicare	$39.10
Rate for Payer: EmblemHealth Select Care	$82.80
Rate for Payer: Fidelis Medicare	$43.83
Rate for Payer: Galaxy Health Commercial	$74.75
Rate for Payer: Hamaspik Choice Medicare	$42.55
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Local 1199SEIU Aetna Signature Administrators	$112.00
Rate for Payer: Local 1199SEIU Medicare	$52.90
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	$44.68
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	$42.55
Rate for Payer: WellCare Medicare	$63.25

OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS (W/ KX)

Facility

$115.00

Service Code	HCPCS 97542 GO,KX
Hospital Charge Code	4690189
Hospital Revenue Code	430
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$86.25
Rate for Payer: Galaxy Health Commercial	$74.75

Know your out-of-pocket cost for care.

All Charges