|
OTM PARAFFIN BATH
|
Facility
|
OP
|
$18.10
|
|
|
Service Code
|
HCPCS 97018 GO
|
| Hospital Charge Code |
41804472
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$6.85 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.85
|
| Rate for Payer: Aetna Government |
$6.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$65.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$65.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$29.02
|
| Rate for Payer: Amida Care Medicaid |
$29.02
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,902.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$29.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30.47
|
| Rate for Payer: Group Health Inc Commercial |
$9.05
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.02
|
| Rate for Payer: Healthfirst Essential Plan |
$65.30
|
| Rate for Payer: Healthfirst QHP |
$29.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$29.02
|
| Rate for Payer: SOMOS Essential |
$65.30
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$65.30
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$31.92
|
| Rate for Payer: United Healthcare Medicaid |
$29.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$29.02
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM PHYSICAL PERFORMANCE TEST 15M
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
HCPCS 97750 GO
|
| Hospital Charge Code |
41804505
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.85
|
| Rate for Payer: Aetna Government |
$19.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$47.88
|
| Rate for Payer: Amida Care Medicaid |
$47.88
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,788.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.27
|
| Rate for Payer: Group Health Inc Commercial |
$51.00
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Healthfirst Essential Plan |
$107.73
|
| Rate for Payer: Healthfirst QHP |
$47.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$47.88
|
| Rate for Payer: SOMOS Essential |
$107.73
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$107.73
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52.67
|
| Rate for Payer: United Healthcare Medicaid |
$47.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM PLATE GUARD
|
Facility
|
OP
|
$12.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804520
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$10.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$9.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.68
|
| Rate for Payer: Group Health Inc Commercial |
$6.38
|
| Rate for Payer: Group Health Inc Medicare |
$4.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.38
|
|
|
OT MP/PIP/BLOCKERS
|
Facility
|
OP
|
$48.91
|
|
|
Service Code
|
HCPCS S8450
|
| Hospital Charge Code |
41809380
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$51.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.14
|
| Rate for Payer: Aetna Government |
$9.14
|
| Rate for Payer: Brighton Health Commercial |
$29.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.12
|
| Rate for Payer: EmblemHealth Commercial |
$24.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$51.36
|
| Rate for Payer: Group Health Inc Commercial |
$24.46
|
| Rate for Payer: Group Health Inc Medicare |
$17.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.79
|
|
|
OTM PROSTHETIC TRAIN-EXTREM 15MTS
|
Facility
|
OP
|
$122.90
|
|
|
Service Code
|
HCPCS 97761
|
| Hospital Charge Code |
41804497
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$67.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.85
|
| Rate for Payer: Aetna Government |
$19.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$47.88
|
| Rate for Payer: Amida Care Medicaid |
$47.88
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,788.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.27
|
| Rate for Payer: Group Health Inc Commercial |
$61.45
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Healthfirst Essential Plan |
$107.73
|
| Rate for Payer: Healthfirst QHP |
$47.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$47.88
|
| Rate for Payer: SOMOS Essential |
$107.73
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$107.73
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52.67
|
| Rate for Payer: United Healthcare Medicaid |
$47.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM REACHER
|
Facility
|
OP
|
$26.93
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804530
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$21.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$20.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.31
|
| Rate for Payer: Group Health Inc Commercial |
$13.46
|
| Rate for Payer: Group Health Inc Medicare |
$9.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.46
|
|
|
OTM RE-EVALUATION
|
Facility
|
OP
|
$183.80
|
|
|
Service Code
|
HCPCS 97168 GO
|
| Hospital Charge Code |
41804467
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$10,278.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.45
|
| Rate for Payer: Aetna Government |
$31.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$231.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$231.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$102.78
|
| Rate for Payer: Amida Care Medicaid |
$102.78
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$10,278.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$102.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$102.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$107.92
|
| Rate for Payer: Group Health Inc Commercial |
$91.90
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$91.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$102.78
|
| Rate for Payer: Healthfirst Essential Plan |
$231.26
|
| Rate for Payer: Healthfirst QHP |
$102.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$102.78
|
| Rate for Payer: SOMOS Essential |
$231.26
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$231.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$113.06
|
| Rate for Payer: United Healthcare Medicaid |
$102.78
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$102.78
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM RESTING HAND SPLINT
|
Facility
|
OP
|
$326.03
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
41804100
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$114.11 |
| Max. Negotiated Rate |
$342.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$195.89
|
| Rate for Payer: Aetna Government |
$195.89
|
| Rate for Payer: Brighton Health Commercial |
$195.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$163.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$187.47
|
| Rate for Payer: EmblemHealth Commercial |
$163.02
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.33
|
| Rate for Payer: Group Health Inc Commercial |
$163.02
|
| Rate for Payer: Group Health Inc Medicare |
$114.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$211.92
|
|
|
OTM RESTING SPLINT
|
Facility
|
OP
|
$570.55
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
41803950
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.32 |
| Max. Negotiated Rate |
$599.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$313.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.32
|
| Rate for Payer: Aetna Government |
$38.32
|
| Rate for Payer: Brighton Health Commercial |
$342.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$285.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$328.07
|
| Rate for Payer: EmblemHealth Commercial |
$285.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$599.08
|
| Rate for Payer: Group Health Inc Commercial |
$285.28
|
| Rate for Payer: Group Health Inc Medicare |
$199.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$370.86
|
|
|
OTM ROM -EACH EXTREMITY/TRUNK
|
Facility
|
OP
|
$23.33
|
|
|
Service Code
|
HCPCS 95851 GO
|
| Hospital Charge Code |
41804508
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.18
|
| Rate for Payer: Aetna Government |
$16.18
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Group Health Inc Commercial |
$11.66
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.66
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM ROM- HAND
|
Facility
|
OP
|
$17.48
|
|
|
Service Code
|
HCPCS 95852 GO
|
| Hospital Charge Code |
41804509
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Group Health Inc Commercial |
$8.74
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.74
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM SENSORY INTEGRATIVE TECHNIQUE
|
Facility
|
OP
|
$153.25
|
|
|
Service Code
|
HCPCS 97533
|
| Hospital Charge Code |
41804519
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$5,078.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$84.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.32
|
| Rate for Payer: Aetna Government |
$17.32
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$114.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$114.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$50.78
|
| Rate for Payer: Amida Care Medicaid |
$50.78
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5,078.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$50.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.32
|
| Rate for Payer: Group Health Inc Commercial |
$76.62
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$76.62
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$50.78
|
| Rate for Payer: Healthfirst Essential Plan |
$114.26
|
| Rate for Payer: Healthfirst QHP |
$50.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$50.78
|
| Rate for Payer: SOMOS Essential |
$114.26
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$114.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$55.86
|
| Rate for Payer: United Healthcare Medicaid |
$50.78
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$50.78
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM SERIAL CASTING
|
Facility
|
OP
|
$32.60
|
|
|
Service Code
|
HCPCS L3929
|
| Hospital Charge Code |
41804360
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.50
|
| Rate for Payer: Aetna Government |
$37.50
|
| Rate for Payer: Brighton Health Commercial |
$19.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.74
|
| Rate for Payer: EmblemHealth Commercial |
$16.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.23
|
| Rate for Payer: Group Health Inc Commercial |
$16.30
|
| Rate for Payer: Group Health Inc Medicare |
$11.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.19
|
|
|
OTM SERPENTINE FINGER BASED SPLIN
|
Facility
|
OP
|
$57.06
|
|
|
Service Code
|
HCPCS S8450
|
| Hospital Charge Code |
41804650
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$59.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.14
|
| Rate for Payer: Aetna Government |
$9.14
|
| Rate for Payer: Brighton Health Commercial |
$34.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.81
|
| Rate for Payer: EmblemHealth Commercial |
$28.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.91
|
| Rate for Payer: Group Health Inc Commercial |
$28.53
|
| Rate for Payer: Group Health Inc Medicare |
$19.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.09
|
|
|
OTM SLING
|
Facility
|
OP
|
$16.31
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
41804061
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$13.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.68
|
| Rate for Payer: Aetna Government |
$4.68
|
| Rate for Payer: Brighton Health Commercial |
$12.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.09
|
| Rate for Payer: Group Health Inc Commercial |
$8.16
|
| Rate for Payer: Group Health Inc Medicare |
$5.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.16
|
|
|
OTM SOCK AID
|
Facility
|
OP
|
$14.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804534
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$11.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.13
|
| Rate for Payer: Group Health Inc Commercial |
$7.44
|
| Rate for Payer: Group Health Inc Medicare |
$5.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.44
|
|
|
OTM SPOUT CUP
|
Facility
|
OP
|
$19.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804525
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$14.89
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.50
|
| Rate for Payer: Group Health Inc Commercial |
$9.92
|
| Rate for Payer: Group Health Inc Medicare |
$6.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.92
|
|
|
OTM STATIC PIP EXTENSION SPLINT
|
Facility
|
OP
|
$48.91
|
|
|
Service Code
|
HCPCS S8450
|
| Hospital Charge Code |
41804370
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$51.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.14
|
| Rate for Payer: Aetna Government |
$9.14
|
| Rate for Payer: Brighton Health Commercial |
$29.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.12
|
| Rate for Payer: EmblemHealth Commercial |
$24.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$51.36
|
| Rate for Payer: Group Health Inc Commercial |
$24.46
|
| Rate for Payer: Group Health Inc Medicare |
$17.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.79
|
|
|
OTM STATIC PROG WRIST EXTENSION
|
Facility
|
OP
|
$195.62
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
41804270
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.32 |
| Max. Negotiated Rate |
$205.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$107.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.32
|
| Rate for Payer: Aetna Government |
$38.32
|
| Rate for Payer: Brighton Health Commercial |
$117.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$97.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$112.48
|
| Rate for Payer: EmblemHealth Commercial |
$97.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$205.40
|
| Rate for Payer: Group Health Inc Commercial |
$97.81
|
| Rate for Payer: Group Health Inc Medicare |
$68.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.15
|
|
|
OTM STOCKNETTE (YARD)
|
Facility
|
OP
|
$32.60
|
|
|
Service Code
|
HCPCS Q4051
|
| Hospital Charge Code |
41804085
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.30
|
| Rate for Payer: Aetna Government |
$16.30
|
| Rate for Payer: Brighton Health Commercial |
$24.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.17
|
| Rate for Payer: Group Health Inc Commercial |
$16.30
|
| Rate for Payer: Group Health Inc Medicare |
$11.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.30
|
|
|
OTM SUPER GRIP UTENSILS
|
Facility
|
OP
|
$17.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804524
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$13.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$12.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.57
|
| Rate for Payer: Group Health Inc Commercial |
$8.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.50
|
|
|
OTM THERABAND
|
Facility
|
OP
|
$48.91
|
|
|
Service Code
|
HCPCS A9300
|
| Hospital Charge Code |
41803450
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$39.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.85
|
| Rate for Payer: Aetna Government |
$7.85
|
| Rate for Payer: Brighton Health Commercial |
$36.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.13
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.26
|
| Rate for Payer: Group Health Inc Commercial |
$24.46
|
| Rate for Payer: Group Health Inc Medicare |
$17.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.46
|
|
|
OTM THER.PROCE-ONE/MORE AREAS 15M
|
Facility
|
OP
|
$89.10
|
|
|
Service Code
|
HCPCS 97110 GO
|
| Hospital Charge Code |
41804484
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.41 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.41
|
| Rate for Payer: Aetna Government |
$19.41
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$47.88
|
| Rate for Payer: Amida Care Medicaid |
$47.88
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,788.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.27
|
| Rate for Payer: Group Health Inc Commercial |
$44.55
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Healthfirst Essential Plan |
$107.73
|
| Rate for Payer: Healthfirst QHP |
$47.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$47.88
|
| Rate for Payer: SOMOS Essential |
$107.73
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$107.73
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52.67
|
| Rate for Payer: United Healthcare Medicaid |
$47.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM THER. PROC. GROUP(2 OR MORE)
|
Facility
|
OP
|
$52.88
|
|
|
Service Code
|
HCPCS 97150 GO
|
| Hospital Charge Code |
41804495
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.34
|
| Rate for Payer: Aetna Government |
$10.34
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Group Health Inc Commercial |
$26.44
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.44
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM THUMB SPICA
|
Facility
|
OP
|
$978.08
|
|
|
Service Code
|
HCPCS L3808
|
| Hospital Charge Code |
41804070
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$188.97 |
| Max. Negotiated Rate |
$1,026.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$537.94
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$188.97
|
| Rate for Payer: Aetna Government |
$188.97
|
| Rate for Payer: Brighton Health Commercial |
$586.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$489.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$562.40
|
| Rate for Payer: EmblemHealth Commercial |
$489.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,026.98
|
| Rate for Payer: Group Health Inc Commercial |
$489.04
|
| Rate for Payer: Group Health Inc Medicare |
$342.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$489.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$489.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$635.75
|
|
