|
OT ELECTRIC CURRENT THERAPY EA 15 MINS
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO
|
| Hospital Charge Code |
4690010
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.40
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: EmblemHealth Select Care |
$51.12
|
| Rate for Payer: Fidelis Medicare |
$28.40
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.40
|
| Rate for Payer: Humana Medicare |
$28.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.82
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$28.40
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (MOD 59)
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,59
|
| Hospital Charge Code |
4690213
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (MOD 59)
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,59
|
| Hospital Charge Code |
4690213
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.40
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: EmblemHealth Select Care |
$51.12
|
| Rate for Payer: Fidelis Medicare |
$28.40
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.40
|
| Rate for Payer: Humana Medicare |
$28.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.82
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$28.40
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,59,KX
|
| Hospital Charge Code |
4690244
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.40
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: EmblemHealth Select Care |
$51.12
|
| Rate for Payer: Fidelis Medicare |
$28.40
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.40
|
| Rate for Payer: Humana Medicare |
$28.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.82
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$28.40
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,59,KX
|
| Hospital Charge Code |
4690244
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (W/ KX)
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,KX
|
| Hospital Charge Code |
4690178
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.40
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: EmblemHealth Select Care |
$51.12
|
| Rate for Payer: Fidelis Medicare |
$28.40
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.40
|
| Rate for Payer: Humana Medicare |
$28.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.82
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.65
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$28.40
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
OT ELECTRIC CURRENT THERAPY EA 15 MINS (W/ KX)
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 97033 GO,KX
|
| Hospital Charge Code |
4690178
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS
|
Facility
|
IP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO
|
| Hospital Charge Code |
4690004
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.30 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS
|
Facility
|
OP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO
|
| Hospital Charge Code |
4690004
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$49.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.26
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: CDPHP Medicare |
$40.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$86.52
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$36.77
|
| Rate for Payer: EmblemHealth Select Care |
$77.87
|
| Rate for Payer: Fidelis Medicare |
$43.26
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.26
|
| Rate for Payer: Humana Medicare |
$43.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.75
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$59.48
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (MOD 59)
|
Facility
|
IP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,59
|
| Hospital Charge Code |
4690207
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.30 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (MOD 59)
|
Facility
|
OP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,59
|
| Hospital Charge Code |
4690207
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$49.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.26
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: CDPHP Medicare |
$40.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$86.52
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$36.77
|
| Rate for Payer: EmblemHealth Select Care |
$77.87
|
| Rate for Payer: Fidelis Medicare |
$43.26
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.26
|
| Rate for Payer: Humana Medicare |
$43.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.75
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$59.48
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (MOD 59 W KX)
|
Facility
|
OP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,59,KX
|
| Hospital Charge Code |
4690238
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$49.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.26
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: CDPHP Medicare |
$40.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$86.52
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$36.77
|
| Rate for Payer: EmblemHealth Select Care |
$77.87
|
| Rate for Payer: Fidelis Medicare |
$43.26
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.26
|
| Rate for Payer: Humana Medicare |
$43.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.75
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$59.48
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (MOD 59 W KX)
|
Facility
|
IP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,59,KX
|
| Hospital Charge Code |
4690238
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.30 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (W/ KX)
|
Facility
|
OP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,KX
|
| Hospital Charge Code |
4690172
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$49.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.26
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: CDPHP Medicare |
$40.02
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$86.52
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$36.77
|
| Rate for Payer: EmblemHealth Select Care |
$77.87
|
| Rate for Payer: Fidelis Medicare |
$43.26
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.26
|
| Rate for Payer: Humana Medicare |
$43.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.75
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$59.48
|
|
|
OT ELECTRIC STIMULATION THERAPY 1+ AREAS (W/ KX)
|
Facility
|
IP
|
$108.15
|
|
|
Service Code
|
HCPCS 97014 GO,KX
|
| Hospital Charge Code |
4690172
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$70.30 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Cash Price |
$81.11
|
| Rate for Payer: Galaxy Health Commercial |
$70.30
|
|
|
OT EVAL HIGH COMPLEX 60 MIN
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO
|
| Hospital Charge Code |
4690002
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$54.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$146.00
|
| 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 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 |
$158.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$132.31
|
| Rate for Payer: EmblemHealth Medicaid |
$132.31
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Galaxy Health Workers Comp |
$129.66
|
| Rate for Payer: Hamaspik Choice Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Medicare |
$146.00
|
| Rate for Payer: Humana Medicare |
$146.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$138.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$153.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$138.93
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL HIGH COMPLEX 60 MIN
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO
|
| Hospital Charge Code |
4690002
|
|
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 (MOD 59)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,59
|
| Hospital Charge Code |
4690205
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$54.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$146.00
|
| 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 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 |
$158.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$132.31
|
| Rate for Payer: EmblemHealth Medicaid |
$132.31
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Galaxy Health Workers Comp |
$129.66
|
| Rate for Payer: Hamaspik Choice Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Medicare |
$146.00
|
| Rate for Payer: Humana Medicare |
$146.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$138.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$153.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$138.93
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
OT EVAL HIGH COMPLEX 60 MIN (MOD 59)
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,59
|
| Hospital Charge Code |
4690205
|
|
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 (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 (MOD 59 W KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97167 GO,59,KX
|
| Hospital Charge Code |
4690236
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$54.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$146.00
|
| 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 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 |
$158.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$132.31
|
| Rate for Payer: EmblemHealth Medicaid |
$132.31
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Galaxy Health Workers Comp |
$129.66
|
| Rate for Payer: Hamaspik Choice Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Medicare |
$146.00
|
| Rate for Payer: Humana Medicare |
$146.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$138.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$153.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$138.93
|
| Rate for Payer: WellCare Medicare |
$200.75
|
|
|
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 |
$54.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$146.00
|
| 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 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 |
$158.77
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$132.31
|
| Rate for Payer: EmblemHealth Medicaid |
$132.31
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Galaxy Health Workers Comp |
$129.66
|
| Rate for Payer: Hamaspik Choice Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Medicare |
$146.00
|
| Rate for Payer: Humana Medicare |
$146.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$138.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$284.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$153.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$138.93
|
| 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 |
$54.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$167.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$146.00
|
| 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 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 |
$95.27
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$79.39
|
| Rate for Payer: EmblemHealth Medicaid |
$79.39
|
| Rate for Payer: EmblemHealth Medicare |
$124.10
|
| Rate for Payer: EmblemHealth Select Care |
$262.80
|
| Rate for Payer: Fidelis Medicare |
$146.00
|
| Rate for Payer: Galaxy Health Commercial |
$237.25
|
| Rate for Payer: Galaxy Health Workers Comp |
$77.80
|
| Rate for Payer: Hamaspik Choice Medicaid |
$79.39
|
| Rate for Payer: Hamaspik Choice Medicare |
$146.00
|
| Rate for Payer: Humana Medicare |
$146.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$167.90
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$83.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$170.69
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$170.69
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$153.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$83.36
|
| 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
|
|
