|
OTM THUMB SPICA -FOREARM
|
Facility
|
OP
|
$211.92
|
|
|
Service Code
|
HCPCS L3808
|
| Hospital Charge Code |
41804230
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$74.17 |
| Max. Negotiated Rate |
$222.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$116.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$188.97
|
| Rate for Payer: Aetna Government |
$188.97
|
| Rate for Payer: Brighton Health Commercial |
$127.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$105.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$121.85
|
| Rate for Payer: EmblemHealth Commercial |
$105.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$222.52
|
| Rate for Payer: Group Health Inc Commercial |
$105.96
|
| Rate for Payer: Group Health Inc Medicare |
$74.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$105.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$137.75
|
|
|
OTM THUMB SPICA -HAND BASED
|
Facility
|
OP
|
$97.81
|
|
|
Service Code
|
HCPCS L3808
|
| Hospital Charge Code |
41804240
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.23 |
| Max. Negotiated Rate |
$188.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$53.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$188.97
|
| Rate for Payer: Aetna Government |
$188.97
|
| Rate for Payer: Brighton Health Commercial |
$58.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$48.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.24
|
| Rate for Payer: EmblemHealth Commercial |
$48.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$102.70
|
| Rate for Payer: Group Health Inc Commercial |
$48.90
|
| Rate for Payer: Group Health Inc Medicare |
$34.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$48.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$63.58
|
|
|
OTM ULNAR GUTTER
|
Facility
|
OP
|
$244.52
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
41804200
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$85.58 |
| Max. Negotiated Rate |
$256.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$195.89
|
| Rate for Payer: Aetna Government |
$195.89
|
| Rate for Payer: Brighton Health Commercial |
$146.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$140.60
|
| Rate for Payer: EmblemHealth Commercial |
$122.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$256.75
|
| Rate for Payer: Group Health Inc Commercial |
$122.26
|
| Rate for Payer: Group Health Inc Medicare |
$85.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$158.94
|
|
|
OTM ULTRASOUND 15 MTS
|
Facility
|
OP
|
$42.05
|
|
|
Service Code
|
HCPCS 97035 GO
|
| Hospital Charge Code |
41804481
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$23.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.63
|
| Rate for Payer: Aetna Government |
$7.63
|
| 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 |
$21.02
|
| 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 |
$21.02
|
| 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 UNLISTED MODALITY
|
Facility
|
OP
|
$36.86
|
|
|
Service Code
|
HCPCS 97039 GO
|
| Hospital Charge Code |
41804483
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.02 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.02
|
| Rate for Payer: Aetna Government |
$11.02
|
| 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 |
$18.43
|
| 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 |
$18.43
|
| 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 UNLISTED OT PROCEDURE
|
Facility
|
OP
|
$70.88
|
|
|
Service Code
|
HCPCS 97799 GO
|
| Hospital Charge Code |
41804507
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$29.02 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.44
|
| Rate for Payer: Aetna Government |
$35.44
|
| 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 |
$35.44
|
| 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 |
$35.44
|
| 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 UNLISTED THER.PROCEDURE 15MTS
|
Facility
|
OP
|
$31.19
|
|
|
Service Code
|
HCPCS 97139 GO
|
| Hospital Charge Code |
41804493
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.91 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.91
|
| Rate for Payer: Aetna Government |
$14.91
|
| 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 |
$15.60
|
| 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 |
$15.60
|
| 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 UTENSIL HOLDER
|
Facility
|
OP
|
$9.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804528
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$7.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.75
|
| Rate for Payer: Group Health Inc Commercial |
$4.96
|
| Rate for Payer: Group Health Inc Medicare |
$3.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.96
|
|
|
OTM VASOPNEUMATIC DEVICE
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
HCPCS 97016 GO
|
| Hospital Charge Code |
41804471
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.69
|
| Rate for Payer: Aetna Government |
$11.69
|
| 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 |
$17.99
|
| 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 |
$17.99
|
| 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 VOCATIONAL REHAB 15 MTS
|
Facility
|
OP
|
$95.18
|
|
|
Service Code
|
HCPCS 97537 GO
|
| Hospital Charge Code |
41803500
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$5,078.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$52.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.08
|
| Rate for Payer: Aetna Government |
$18.08
|
| 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 |
$47.59
|
| 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 |
$47.59
|
| 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 WEIGHTED UTENSILS
|
Facility
|
OP
|
$17.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41804523
|
|
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 WHEEL CHAIR TRAINING 15 MTS
|
Facility
|
OP
|
$96.25
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
41804501
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.52 |
| Max. Negotiated Rate |
$5,477.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$52.94
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.52
|
| Rate for Payer: Aetna Government |
$18.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$123.23
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$123.23
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$54.77
|
| Rate for Payer: Amida Care Medicaid |
$54.77
|
| 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 |
$5,477.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$54.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$54.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$57.51
|
| Rate for Payer: Group Health Inc Commercial |
$48.12
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$54.77
|
| Rate for Payer: Healthfirst Essential Plan |
$123.23
|
| Rate for Payer: Healthfirst QHP |
$54.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$54.77
|
| Rate for Payer: SOMOS Essential |
$123.23
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$123.23
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$60.25
|
| Rate for Payer: United Healthcare Medicaid |
$54.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$54.77
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM WHIRLPOOL
|
Facility
|
OP
|
$53.30
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
41804474
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.37 |
| Max. Negotiated Rate |
$2,902.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.37
|
| Rate for Payer: Aetna Government |
$14.37
|
| 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 |
$26.65
|
| 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 |
$26.65
|
| 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 WOUND CARE-SELECTIVE DEBRDMNT
|
Facility
|
IP
|
$529.23
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
41804518
|
|
Hospital Revenue Code
|
430
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
OTM WOUND CARE-SELECTIVE DEBRDMNT
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
41804518
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$291.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$291.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$231.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$231.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OTM WRIST EXTENSION STATIC
|
Facility
|
OP
|
$154.86
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
41804290
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.32 |
| Max. Negotiated Rate |
$162.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.32
|
| Rate for Payer: Aetna Government |
$38.32
|
| Rate for Payer: Brighton Health Commercial |
$92.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$77.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$89.04
|
| Rate for Payer: EmblemHealth Commercial |
$77.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$162.60
|
| Rate for Payer: Group Health Inc Commercial |
$77.43
|
| Rate for Payer: Group Health Inc Medicare |
$54.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$100.66
|
|
|
OTM WRIST SPLINT
|
Facility
|
OP
|
$247.71
|
|
|
Service Code
|
HCPCS L3908
|
| Hospital Charge Code |
41804068
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.32 |
| Max. Negotiated Rate |
$260.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$136.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.32
|
| Rate for Payer: Aetna Government |
$38.32
|
| Rate for Payer: Brighton Health Commercial |
$148.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$123.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$142.43
|
| Rate for Payer: EmblemHealth Commercial |
$123.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$260.10
|
| Rate for Payer: Group Health Inc Commercial |
$123.86
|
| Rate for Payer: Group Health Inc Medicare |
$86.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$123.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$123.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$161.01
|
|
|
OT NEGATIVE PRESSURE<50SQ.CM
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
41809561
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$291.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$291.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$231.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$231.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OT NEGATIVE PRESSURE<50SQ.CM
|
Facility
|
IP
|
$529.23
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
41809561
|
|
Hospital Revenue Code
|
430
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
OT NEGATIVE PRESSURE>50SQ.CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
41809560
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$532.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$532.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
OT NEGATIVE PRESSURE>50SQ.CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
41809560
|
|
Hospital Revenue Code
|
430
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
OT NEUROMUSCULAR REEDUCATION 15MT
|
Facility
|
OP
|
$102.45
|
|
|
Service Code
|
HCPCS 97112 GO
|
| Hospital Charge Code |
41809489
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$20.29 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.29
|
| Rate for Payer: Aetna Government |
$20.29
|
| 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 |
$51.22
|
| 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 |
$51.22
|
| 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
|
|
|
OT NON-SKID MATERIAL
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41809529
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$71.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$66.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$71.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$60.72
|
| Rate for Payer: Group Health Inc Commercial |
$44.65
|
| Rate for Payer: Group Health Inc Medicare |
$31.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.65
|
|
|
OT NOSEY CUP
|
Facility
|
OP
|
$8.51
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
41809522
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$6.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$6.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.79
|
| Rate for Payer: Group Health Inc Commercial |
$4.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.26
|
|
|
Otolaryngologic examination under general anesthesia
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 92502
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$445.39 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$636.27
|
| Rate for Payer: Aetna Government |
$636.27
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$445.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$445.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$445.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$636.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$636.27
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$540.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$566.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$636.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$566.28
|
| Rate for Payer: Group Health Inc Commercial |
$636.27
|
| Rate for Payer: Group Health Inc Medicare |
$636.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$636.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$540.83
|
| Rate for Payer: Healthfirst QHP |
$636.27
|
| Rate for Payer: Humana Medicare |
$649.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$636.27
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$636.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$636.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$509.02
|
| Rate for Payer: Wellcare Medicare |
$604.46
|
|
