Adaptive Behavior Assessment Procedure
|
Professional
|
$45.00
|
|
Service Code
|
CPT 97151
|
Hospital Charge Code |
1
|
Min. Negotiated Rate |
$23.55 |
Max. Negotiated Rate |
$41.67 |
Rate for Payer: Aetna Medicaid |
$23.55
|
Rate for Payer: BCBS Blue Traditional |
$41.67
|
Rate for Payer: Cash Price |
$23.55
|
Rate for Payer: Humana Medicaid |
$23.55
|
Rate for Payer: Oklahoma Complete Medicaid |
$23.55
|
Rate for Payer: Sooner Care Medicaid |
$23.55
|
Rate for Payer: TRICARE TRICARE |
$40.00
|
|
Applied Behavior Analysis (BCBA/BCABA Treatment)
|
Professional
|
$45.00
|
|
Service Code
|
CPT 97155
|
Hospital Charge Code |
2
|
Min. Negotiated Rate |
$23.55 |
Max. Negotiated Rate |
$32.00 |
Rate for Payer: Aetna Medicaid |
$23.55
|
Rate for Payer: BCBS Blue Traditional |
$24.21
|
Rate for Payer: Cash Price |
$23.55
|
Rate for Payer: Humana Medicaid |
$23.55
|
Rate for Payer: Oklahoma Complete Medicaid |
$23.55
|
Rate for Payer: Sooner Care Medicaid |
$23.55
|
Rate for Payer: TRICARE TRICARE |
$32.00
|
|
Applied Behavior Analysis (Parent Training)
|
Professional
|
$45.00
|
|
Service Code
|
CPT 97156
|
Hospital Charge Code |
3
|
Min. Negotiated Rate |
$23.08 |
Max. Negotiated Rate |
$29.00 |
Rate for Payer: Aetna Medicaid |
$23.55
|
Rate for Payer: BCBS Blue Traditional |
$23.08
|
Rate for Payer: Cash Price |
$23.55
|
Rate for Payer: Humana Medicaid |
$23.55
|
Rate for Payer: Oklahoma Complete Medicaid |
$23.55
|
Rate for Payer: Sooner Care Medicaid |
$23.55
|
Rate for Payer: TRICARE TRICARE |
$29.00
|
|
Applied Behavior Analysis (RBT Treatment)
|
Professional
|
$35.00
|
|
Service Code
|
CPT 97153
|
Hospital Charge Code |
4
|
Min. Negotiated Rate |
$12.11 |
Max. Negotiated Rate |
$21.00 |
Rate for Payer: Aetna Medicaid |
$17.35
|
Rate for Payer: BCBS Blue Traditional |
$12.11
|
Rate for Payer: Cash Price |
$17.35
|
Rate for Payer: Humana Medicaid |
$17.35
|
Rate for Payer: Oklahoma Complete Medicaid |
$17.35
|
Rate for Payer: Sooner Care Medicaid |
$17.35
|
Rate for Payer: TRICARE TRICARE |
$21.00
|
|
Complex Cranial Nerve Neurostimulator
|
Professional
|
$70.00
|
|
Service Code
|
CPT 95977
|
Hospital Charge Code |
5
|
Min. Negotiated Rate |
$35.21 |
Max. Negotiated Rate |
$174.67 |
Rate for Payer: Aetna Medicaid |
$46.37
|
Rate for Payer: BCBS Blue Traditional |
$44.33
|
Rate for Payer: Cash Price |
$46.37
|
Rate for Payer: HealthChoice Medicaid |
$174.67
|
Rate for Payer: Humana Medicaid |
$46.37
|
Rate for Payer: Oklahoma Complete Medicaid |
$46.37
|
Rate for Payer: Sooner Care Medicaid |
$46.37
|
Rate for Payer: TRICARE TRICARE |
$50.29
|
Rate for Payer: United Health Medicaid |
$35.21
|
|
Electric Analysis of Implanted Neurostimulator
|
Professional
|
$75.00
|
|
Service Code
|
CPT 95970
|
Hospital Charge Code |
6
|
Min. Negotiated Rate |
$12.64 |
Max. Negotiated Rate |
$18.05 |
Rate for Payer: Aetna Medicaid |
$16.67
|
Rate for Payer: BCBS Blue Traditional |
$15.79
|
Rate for Payer: Cash Price |
$16.67
|
Rate for Payer: Humana Medicaid |
$16.67
|
Rate for Payer: Oklahoma Complete Medicaid |
$16.67
|
Rate for Payer: Sooner Care Medicaid |
$16.67
|
Rate for Payer: TRICARE TRICARE |
$18.05
|
Rate for Payer: United Health Medicaid |
$12.64
|
|
Established Outpatient (Level 1)
|
Professional
|
$40.00
|
|
Service Code
|
CPT 99211
|
Hospital Charge Code |
7
|
Min. Negotiated Rate |
$7.59 |
Max. Negotiated Rate |
$32.33 |
Rate for Payer: Aetna Medicaid |
$20.03
|
Rate for Payer: BCBS Blue Traditional |
$7.59
|
Rate for Payer: Cash Price |
$20.03
|
Rate for Payer: HealthChoice Medicaid |
$32.33
|
Rate for Payer: Humana Medicaid |
$20.03
|
Rate for Payer: Oklahoma Complete Medicaid |
$20.03
|
Rate for Payer: Sooner Care Medicaid |
$20.03
|
Rate for Payer: TRICARE TRICARE |
$21.38
|
Rate for Payer: United Health Medicaid |
$14.97
|
|
Established Outpatient (Level 2)
|
Professional
|
$65.00
|
|
Service Code
|
CPT 99212
|
Hospital Charge Code |
8
|
Min. Negotiated Rate |
$37.08 |
Max. Negotiated Rate |
$80.09 |
Rate for Payer: Aetna Medicaid |
$49.44
|
Rate for Payer: BCBS Blue Traditional |
$56.57
|
Rate for Payer: Cash Price |
$49.44
|
Rate for Payer: HealthChoice Medicaid |
$80.09
|
Rate for Payer: Humana Medicaid |
$49.44
|
Rate for Payer: Oklahoma Complete Medicaid |
$49.44
|
Rate for Payer: Sooner Care Medicaid |
$49.44
|
Rate for Payer: TRICARE TRICARE |
$52.97
|
Rate for Payer: United Health Medicaid |
$37.08
|
|
Established Outpatient (Level 3)
|
Professional
|
$95.00
|
|
Service Code
|
CPT 99213
|
Hospital Charge Code |
9
|
Min. Negotiated Rate |
$30.06 |
Max. Negotiated Rate |
$128.82 |
Rate for Payer: Aetna Medicaid |
$79.99
|
Rate for Payer: BCBS Blue Traditional |
$30.06
|
Rate for Payer: Cash Price |
$79.99
|
Rate for Payer: HealthChoice Medicaid |
$128.82
|
Rate for Payer: Humana Medicaid |
$79.99
|
Rate for Payer: Oklahoma Complete Medicaid |
$79.99
|
Rate for Payer: Sooner Care Medicaid |
$79.99
|
Rate for Payer: TRICARE TRICARE |
$85.19
|
Rate for Payer: United Health Medicaid |
$59.63
|
|
Established Outpatient (Level 4)
|
Professional
|
$150.00
|
|
Service Code
|
CPT 99214
|
Hospital Charge Code |
10
|
Min. Negotiated Rate |
$83.49 |
Max. Negotiated Rate |
$182.65 |
Rate for Payer: Aetna Medicaid |
$113.10
|
Rate for Payer: BCBS Blue Traditional |
$83.49
|
Rate for Payer: Cash Price |
$113.10
|
Rate for Payer: HealthChoice Medicaid |
$182.65
|
Rate for Payer: Humana Medicaid |
$113.10
|
Rate for Payer: Oklahoma Complete Medicaid |
$113.10
|
Rate for Payer: Sooner Care Medicaid |
$113.10
|
Rate for Payer: TRICARE TRICARE |
$120.79
|
Rate for Payer: United Health Medicaid |
$84.55
|
|
Established Outpatient (Level 5)
|
Professional
|
$180.00
|
|
Service Code
|
CPT 99215
|
Hospital Charge Code |
11
|
Min. Negotiated Rate |
$118.76 |
Max. Negotiated Rate |
$256.54 |
Rate for Payer: Aetna Medicaid |
$159.49
|
Rate for Payer: BCBS Blue Traditional |
$122.96
|
Rate for Payer: Cash Price |
$159.49
|
Rate for Payer: HealthChoice Medicaid |
$256.54
|
Rate for Payer: Humana Medicaid |
$159.49
|
Rate for Payer: Oklahoma Complete Medicaid |
$159.49
|
Rate for Payer: Sooner Care Medicaid |
$159.49
|
Rate for Payer: TRICARE TRICARE |
$169.65
|
Rate for Payer: United Health Medicaid |
$118.76
|
|
Feeding and Swallowing Evaluation
|
Facility
IP
|
$150.00
|
|
Service Code
|
CPT 92610
|
Hospital Charge Code |
12
|
Hospital Revenue Code
|
440
|
Min. Negotiated Rate |
$56.60 |
Max. Negotiated Rate |
$122.28 |
Rate for Payer: BCBS Blue Traditional |
$58.90
|
Rate for Payer: HealthChoice Medicaid |
$122.28
|
Rate for Payer: Humana Medicaid |
$75.41
|
Rate for Payer: Oklahoma Complete Medicaid |
$75.41
|
Rate for Payer: Sooner Care Medicaid |
$75.41
|
Rate for Payer: TRICARE TRICARE |
$80.86
|
Rate for Payer: United Health Medicaid |
$56.60
|
|
Feeding and Swallowing Evaluation
|
Facility
OP
|
$150.00
|
|
Service Code
|
CPT 92610
|
Hospital Charge Code |
13
|
Hospital Revenue Code
|
440
|
Min. Negotiated Rate |
$56.60 |
Max. Negotiated Rate |
$122.28 |
Rate for Payer: Aetna Medicaid |
$75.41
|
Rate for Payer: BCBS Blue Traditional |
$58.90
|
Rate for Payer: Cash Price |
$75.41
|
Rate for Payer: HealthChoice Medicaid |
$122.28
|
Rate for Payer: Humana Medicaid |
$75.41
|
Rate for Payer: Oklahoma Complete Medicaid |
$75.41
|
Rate for Payer: Sooner Care Medicaid |
$75.41
|
Rate for Payer: TRICARE TRICARE |
$80.86
|
Rate for Payer: United Health Medicaid |
$56.60
|
|
Feeding and Swallowing Therapy
|
Facility
IP
|
$120.00
|
|
Service Code
|
CPT 92526
|
Hospital Charge Code |
14
|
Hospital Revenue Code
|
440
|
Min. Negotiated Rate |
$56.71 |
Max. Negotiated Rate |
$122.51 |
Rate for Payer: Aetna Medicaid |
$75.02
|
Rate for Payer: BCBS Blue Traditional |
$71.04
|
Rate for Payer: HealthChoice Medicaid |
$122.51
|
Rate for Payer: Humana Medicaid |
$75.02
|
Rate for Payer: Oklahoma Complete Medicaid |
$75.02
|
Rate for Payer: Sooner Care Medicaid |
$75.02
|
Rate for Payer: TRICARE TRICARE |
$81.02
|
Rate for Payer: United Health Medicaid |
$56.71
|
|
Feeding and Swallowing Therapy
|
Facility
OP
|
$120.00
|
|
Service Code
|
CPT 92526
|
Hospital Charge Code |
15
|
Hospital Revenue Code
|
440
|
Min. Negotiated Rate |
$56.71 |
Max. Negotiated Rate |
$122.51 |
Rate for Payer: Aetna Medicaid |
$75.02
|
Rate for Payer: BCBS Blue Traditional |
$71.04
|
Rate for Payer: Cash Price |
$75.02
|
Rate for Payer: HealthChoice Medicaid |
$122.51
|
Rate for Payer: Humana Medicaid |
$75.02
|
Rate for Payer: Oklahoma Complete Medicaid |
$75.02
|
Rate for Payer: Sooner Care Medicaid |
$75.02
|
Rate for Payer: TRICARE TRICARE |
$81.02
|
Rate for Payer: United Health Medicaid |
$56.71
|
|
Initail Outpatient Encounter (Level 5)
|
Professional
|
$225.00
|
|
Service Code
|
CPT 99205
|
Hospital Charge Code |
16
|
Min. Negotiated Rate |
$145.85 |
Max. Negotiated Rate |
$315.07 |
Rate for Payer: Aetna Medicaid |
$161.05
|
Rate for Payer: BCBS Blue Traditional |
$154.84
|
Rate for Payer: Cash Price |
$161.05
|
Rate for Payer: HealthChoice Medicaid |
$315.07
|
Rate for Payer: Humana Medicaid |
$161.05
|
Rate for Payer: Oklahoma Complete Medicaid |
$161.05
|
Rate for Payer: Sooner Care Medicaid |
$161.05
|
Rate for Payer: TRICARE TRICARE |
$208.35
|
Rate for Payer: United Health Medicaid |
$145.85
|
|
Initial Inpatient Enconter (Level 3)
|
Professional
|
$200.00
|
|
Service Code
|
CPT 99223
|
Hospital Charge Code |
17
|
Min. Negotiated Rate |
$116.74 |
Max. Negotiated Rate |
$252.19 |
Rate for Payer: Aetna Medicaid |
$154.00
|
Rate for Payer: BCBS Blue Traditional |
$166.68
|
Rate for Payer: Cash Price |
$154.00
|
Rate for Payer: HealthChoice Medicaid |
$252.19
|
Rate for Payer: Humana Medicaid |
$154.00
|
Rate for Payer: Oklahoma Complete Medicaid |
$154.00
|
Rate for Payer: Sooner Care Medicaid |
$154.00
|
Rate for Payer: TRICARE TRICARE |
$166.77
|
Rate for Payer: United Health Medicaid |
$116.74
|
|
Initial Inpatient Encounter (Level 1)
|
Professional
|
$150.00
|
|
Service Code
|
CPT 99221
|
Hospital Charge Code |
18
|
Min. Negotiated Rate |
$55.73 |
Max. Negotiated Rate |
$120.40 |
Rate for Payer: Aetna Medicaid |
$73.41
|
Rate for Payer: BCBS Blue Traditional |
$83.79
|
Rate for Payer: Cash Price |
$73.41
|
Rate for Payer: HealthChoice Medicaid |
$120.40
|
Rate for Payer: Humana Medicaid |
$73.41
|
Rate for Payer: Oklahoma Complete Medicaid |
$73.41
|
Rate for Payer: Sooner Care Medicaid |
$73.41
|
Rate for Payer: TRICARE TRICARE |
$79.62
|
Rate for Payer: United Health Medicaid |
$55.73
|
|
Initial Inpatient Encounter (Level 2)
|
Professional
|
$175.00
|
|
Service Code
|
CPT 99222
|
Hospital Charge Code |
19
|
Min. Negotiated Rate |
$87.49 |
Max. Negotiated Rate |
$188.99 |
Rate for Payer: Aetna Medicaid |
$116.02
|
Rate for Payer: BCBS Blue Traditional |
$113.24
|
Rate for Payer: Cash Price |
$116.02
|
Rate for Payer: HealthChoice Medicaid |
$188.99
|
Rate for Payer: Humana Medicaid |
$116.02
|
Rate for Payer: Oklahoma Complete Medicaid |
$116.02
|
Rate for Payer: Sooner Care Medicaid |
$116.02
|
Rate for Payer: TRICARE TRICARE |
$124.98
|
Rate for Payer: United Health Medicaid |
$87.49
|
|
Initial Outpatient Encouner (Level 2)
|
Professional
|
$75.00
|
|
Service Code
|
CPT 99202
|
Hospital Charge Code |
20
|
Min. Negotiated Rate |
$41.29 |
Max. Negotiated Rate |
$102.69 |
Rate for Payer: Aetna Medicaid |
$63.23
|
Rate for Payer: BCBS Blue Traditional |
$41.29
|
Rate for Payer: Cash Price |
$63.23
|
Rate for Payer: HealthChoice Medicaid |
$102.69
|
Rate for Payer: Humana Medicaid |
$63.23
|
Rate for Payer: Oklahoma Complete Medicaid |
$63.23
|
Rate for Payer: Sooner Care Medicaid |
$63.23
|
Rate for Payer: TRICARE TRICARE |
$67.91
|
Rate for Payer: United Health Medicaid |
$47.54
|
|
Initial Outpatient Encounter (Level 4)
|
Professional
|
$175.00
|
|
Service Code
|
CPT 99204
|
Hospital Charge Code |
21
|
Min. Negotiated Rate |
$110.38 |
Max. Negotiated Rate |
$238.44 |
Rate for Payer: Aetna Medicaid |
$118.50
|
Rate for Payer: BCBS Blue Traditional |
$114.15
|
Rate for Payer: Cash Price |
$118.50
|
Rate for Payer: HealthChoice Medicaid |
$238.44
|
Rate for Payer: Humana Medicaid |
$118.50
|
Rate for Payer: Oklahoma Complete Medicaid |
$118.50
|
Rate for Payer: Sooner Care Medicaid |
$118.50
|
Rate for Payer: TRICARE TRICARE |
$157.68
|
Rate for Payer: United Health Medicaid |
$110.38
|
|
Initial Outpatinet Encounter (Level 3)
|
Professional
|
$105.00
|
|
Service Code
|
CPT 99203
|
Hospital Charge Code |
22
|
Min. Negotiated Rate |
$70.13 |
Max. Negotiated Rate |
$159.77 |
Rate for Payer: Aetna Medicaid |
$72.81
|
Rate for Payer: BCBS Blue Traditional |
$70.13
|
Rate for Payer: Cash Price |
$72.81
|
Rate for Payer: HealthChoice Medicaid |
$159.77
|
Rate for Payer: Humana Medicaid |
$72.81
|
Rate for Payer: Oklahoma Complete Medicaid |
$72.81
|
Rate for Payer: Sooner Care Medicaid |
$72.81
|
Rate for Payer: TRICARE TRICARE |
$79.23
|
Rate for Payer: United Health Medicaid |
$73.96
|
|
Inpatient Hospital Care (Level 1)
|
Professional
|
$60.00
|
|
Service Code
|
CPT 99231
|
Hospital Charge Code |
23
|
Min. Negotiated Rate |
$31.88 |
Max. Negotiated Rate |
$72.14 |
Rate for Payer: Aetna Medicaid |
$44.00
|
Rate for Payer: BCBS Blue Traditional |
$31.88
|
Rate for Payer: Cash Price |
$44.00
|
Rate for Payer: HealthChoice Medicaid |
$72.14
|
Rate for Payer: Humana Medicaid |
$44.00
|
Rate for Payer: Oklahoma Complete Medicaid |
$44.00
|
Rate for Payer: Sooner Care Medicaid |
$44.00
|
Rate for Payer: TRICARE TRICARE |
$47.70
|
Rate for Payer: United Health Medicaid |
$33.39
|
|
Inpatient Hospital Care (Level 2)
|
Professional
|
$75.00
|
|
Service Code
|
CPT 99232
|
Hospital Charge Code |
24
|
Min. Negotiated Rate |
$53.23 |
Max. Negotiated Rate |
$114.99 |
Rate for Payer: Aetna Medicaid |
$70.09
|
Rate for Payer: BCBS Blue Traditional |
$59.81
|
Rate for Payer: Cash Price |
$70.09
|
Rate for Payer: HealthChoice Medicaid |
$114.99
|
Rate for Payer: Humana Medicaid |
$70.09
|
Rate for Payer: Oklahoma Complete Medicaid |
$70.09
|
Rate for Payer: Sooner Care Medicaid |
$70.09
|
Rate for Payer: TRICARE TRICARE |
$76.04
|
Rate for Payer: United Health Medicaid |
$53.23
|
|
Inpatient Hospital Care (Level 3)
|
Professional
|
$120.00
|
|
Service Code
|
CPT 99233
|
Hospital Charge Code |
25
|
Min. Negotiated Rate |
$80.10 |
Max. Negotiated Rate |
$173.03 |
Rate for Payer: Aetna Medicaid |
$105.47
|
Rate for Payer: BCBS Blue Traditional |
$85.92
|
Rate for Payer: Cash Price |
$105.47
|
Rate for Payer: HealthChoice Medicaid |
$173.03
|
Rate for Payer: Humana Medicaid |
$105.47
|
Rate for Payer: Oklahoma Complete Medicaid |
$105.47
|
Rate for Payer: Sooner Care Medicaid |
$105.47
|
Rate for Payer: TRICARE TRICARE |
$114.42
|
Rate for Payer: United Health Medicaid |
$80.10
|
|