|
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)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,59
|
| Hospital Charge Code |
4690203
|
|
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 (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 (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 |
$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 (W/ KX)
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 97165 GO,KX
|
| Hospital Charge Code |
4690168
|
|
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 (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 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 |
$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 |
$127.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$105.85
|
| Rate for Payer: EmblemHealth Medicaid |
$105.85
|
| 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 |
$103.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$105.85
|
| 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 |
$111.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$227.58
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$227.58
|
| 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 |
$111.14
|
| 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 |
$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 |
$127.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$105.85
|
| Rate for Payer: EmblemHealth Medicaid |
$105.85
|
| 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 |
$103.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$105.85
|
| 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 |
$111.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$227.58
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$227.58
|
| 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 |
$111.14
|
| 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 |
$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 |
$127.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$105.85
|
| Rate for Payer: EmblemHealth Medicaid |
$105.85
|
| 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 |
$103.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$105.85
|
| 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 |
$111.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$227.58
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$227.58
|
| 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 |
$111.14
|
| 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 |
$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 |
$127.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$105.85
|
| Rate for Payer: EmblemHealth Medicaid |
$105.85
|
| 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 |
$103.73
|
| Rate for Payer: Hamaspik Choice Medicaid |
$105.85
|
| 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 |
$111.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$227.58
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$227.58
|
| 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 |
$111.14
|
| 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 |
$18.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.20
|
| 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 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 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$49.20
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.20
|
| Rate for Payer: Humana Medicare |
$49.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$49.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| 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 |
$18.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.20
|
| 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 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 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$49.20
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.20
|
| Rate for Payer: Humana Medicare |
$49.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$49.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| 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
|
|
|
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 |
$18.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.20
|
| 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 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 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$49.20
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.20
|
| Rate for Payer: Humana Medicare |
$49.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$49.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.65
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (W/ KX)
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,KX
|
| Hospital Charge Code |
4690182
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$56.58
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$49.20
|
| 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 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 |
$44.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.98
|
| Rate for Payer: EmblemHealth Medicaid |
$36.98
|
| Rate for Payer: EmblemHealth Medicare |
$41.82
|
| Rate for Payer: EmblemHealth Select Care |
$88.56
|
| Rate for Payer: Fidelis Medicare |
$49.20
|
| Rate for Payer: Galaxy Health Commercial |
$79.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$36.24
|
| Rate for Payer: Hamaspik Choice Medicaid |
$36.98
|
| Rate for Payer: Hamaspik Choice Medicare |
$49.20
|
| Rate for Payer: Humana Medicare |
$49.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$56.58
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$38.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$79.51
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$51.66
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$49.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$38.83
|
| Rate for Payer: WellCare Medicare |
$67.65
|
|
|
OT GAIT TRAINING THERAPY EA 15 MINS (W/ KX)
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 97116 GO,KX
|
| Hospital Charge Code |
4690182
|
|
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 HOT OR COLD PACKS THERAPY 1+ AREAS
|
Facility
|
IP
|
$46.35
|
|
|
Service Code
|
HCPCS 97010 GO
|
| Hospital Charge Code |
4650123
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$30.13 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Galaxy Health Commercial |
$30.13
|
|
|
OT HOT OR COLD PACKS THERAPY 1+ AREAS
|
Facility
|
OP
|
$46.35
|
|
|
Service Code
|
HCPCS 97010 GO
|
| Hospital Charge Code |
4650123
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$21.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.54
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: CDPHP Medicare |
$17.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$37.08
|
| 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 |
$15.76
|
| Rate for Payer: EmblemHealth Select Care |
$33.37
|
| Rate for Payer: Fidelis Medicare |
$18.54
|
| Rate for Payer: Galaxy Health Commercial |
$30.13
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.54
|
| Rate for Payer: Humana Medicare |
$18.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$21.32
|
| 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 |
$19.47
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.95
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$18.54
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$25.49
|
|
|
OT HOT OR COLD PACKS THERAPY 1+ AREAS (MOD 59)
|
Facility
|
IP
|
$46.35
|
|
|
Service Code
|
HCPCS 97010 GO,59
|
| Hospital Charge Code |
4650402
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$30.13 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: Cash Price |
$34.76
|
| Rate for Payer: Galaxy Health Commercial |
$30.13
|
|
