|
HC INJ DIAG/THERA PARAVER FACET JNT - LUMBAR/SACRAL C/T 2ND LEVEL
|
Facility
|
IP
|
$1,229.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
5106449401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$614.50 |
| Max. Negotiated Rate |
$614.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$614.50
|
|
|
HC INJ DIAG/THERA PARAVER FACET JNT - LUMBAR/SACRAL C/T 3RD+ LEVEL
|
Facility
|
OP
|
$1,229.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
5106449501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.86 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60.11
|
| Rate for Payer: Aetna Government |
$60.11
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$614.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$614.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$56.86
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
HC INJ DIAG/THERA PARAVER FACET JNT - LUMBAR/SACRAL C/T 3RD+ LEVEL
|
Facility
|
IP
|
$1,229.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
5106449501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$614.50 |
| Max. Negotiated Rate |
$614.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$614.50
|
|
|
HC INJ DIAG/THERA PARAVER FACET JNT - LUMBAR/SACRAL C/T SINGLE LEVEL
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
5106449301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$1,229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
|
|
HC INJ DIAG/THERA PARAVER FACET JNT - LUMBAR/SACRAL C/T SINGLE LEVEL
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
5106449301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.01 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$103.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,142.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
3616449001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$118.62 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$1,844.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$1,087.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$1,087.77
|
| Rate for Payer: Group Health Inc Medicare |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$118.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
CPT 64490
|
| Hospital Charge Code |
3616449001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$1,229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL
|
Facility
|
IP
|
$2,171.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
3616449301
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,085.50 |
| Max. Negotiated Rate |
$1,085.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,085.50
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL
|
Facility
|
OP
|
$2,171.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
3616449301
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$103.01 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$1,628.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$1,087.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$1,087.77
|
| Rate for Payer: Group Health Inc Medicare |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$103.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 2ND LEVEL
|
Facility
|
IP
|
$2,388.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
3616449401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,194.00 |
| Max. Negotiated Rate |
$1,194.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,194.00
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 2ND LEVEL
|
Facility
|
OP
|
$2,388.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
3616449401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.29
|
| Rate for Payer: Aetna Government |
$59.29
|
| Rate for Payer: Brighton Health Commercial |
$1,791.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: EmblemHealth Commercial |
$1,194.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,194.00
|
| Rate for Payer: Group Health Inc Medicare |
$835.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,194.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,194.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$56.93
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
HC INJECT ABDOMINAL-VENOUS SHUNT
|
Facility
|
IP
|
$2,425.00
|
|
|
Service Code
|
CPT 49427 TC
|
| Hospital Charge Code |
3614942701
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,212.50 |
| Max. Negotiated Rate |
$1,212.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,212.50
|
|
|
HC INJECT ABDOMINAL-VENOUS SHUNT
|
Facility
|
OP
|
$2,425.00
|
|
|
Service Code
|
CPT 49427 TC
|
| Hospital Charge Code |
3614942701
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$53.15 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$53.15
|
| Rate for Payer: Aetna Government |
$53.15
|
| Rate for Payer: Brighton Health Commercial |
$1,818.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: EmblemHealth Commercial |
$1,212.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,212.50
|
| Rate for Payer: Group Health Inc Medicare |
$848.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,212.50
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
HC INJECT CARPAL TUNNEL
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 20526
|
| Hospital Charge Code |
3612052601
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$396.00 |
| Max. Negotiated Rate |
$396.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$396.00
|
|
|
HC INJECT CARPAL TUNNEL
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 20526
|
| Hospital Charge Code |
3612052601
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.29 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$360.67
|
| Rate for Payer: Aetna Government |
$360.67
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$252.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$252.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$252.47
|
| Rate for Payer: Brighton Health Commercial |
$594.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$360.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$360.67
|
| Rate for Payer: EmblemHealth Commercial |
$360.67
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$324.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$306.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$321.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$360.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$321.00
|
| Rate for Payer: Group Health Inc Commercial |
$360.67
|
| Rate for Payer: Group Health Inc Medicare |
$360.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$360.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$306.57
|
| Rate for Payer: Healthfirst QHP |
$360.67
|
| Rate for Payer: Humana Medicare |
$367.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$360.67
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$360.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$360.67
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$342.64
|
| Rate for Payer: Wellcare Medicare |
$342.64
|
|
|
HC INJECT CORPORA CAVERN,PHARM AGNT
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
CPT 54235
|
| Hospital Charge Code |
3615423501
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$355.50 |
| Max. Negotiated Rate |
$355.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$355.50
|
|
|
HC INJECT CORPORA CAVERN,PHARM AGNT
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
CPT 54235
|
| Hospital Charge Code |
3615423501
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.93 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$297.16
|
| Rate for Payer: Aetna Government |
$297.16
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$208.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$208.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$208.01
|
| Rate for Payer: Brighton Health Commercial |
$533.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$297.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$297.16
|
| Rate for Payer: EmblemHealth Commercial |
$297.16
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$267.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$252.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$264.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$297.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$264.47
|
| Rate for Payer: Group Health Inc Commercial |
$297.16
|
| Rate for Payer: Group Health Inc Medicare |
$297.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$297.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$252.59
|
| Rate for Payer: Healthfirst QHP |
$297.16
|
| Rate for Payer: Humana Medicare |
$303.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$297.16
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$297.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$297.16
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$282.30
|
| Rate for Payer: Wellcare Medicare |
$282.30
|
|
|
HC INJECTION, ANESTHETIC AGENT, CELIAC PLEXUS
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
CPT 64530 TC
|
| Hospital Charge Code |
5106453001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$1,229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
|
|
HC INJECTION, ANESTHETIC AGENT, CELIAC PLEXUS
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
CPT 64530 TC
|
| Hospital Charge Code |
5106453001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$184.48 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$218.83
|
| Rate for Payer: Aetna Government |
$218.83
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
HC INJECTION, ANESTHETIC AGENT, LUMBAR THORACIC
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
CPT 64520
|
| Hospital Charge Code |
5106452001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$96.07 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$96.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,142.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
|
HC INJECTION, ANESTHETIC AGENT, LUMBAR THORACIC
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
CPT 64520
|
| Hospital Charge Code |
5106452001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$1,229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
|
|
HC INJECTION, ANESTHETIC AGENT, STELLATE GANGLION
|
Facility
|
IP
|
$1,893.00
|
|
|
Service Code
|
CPT 64510
|
| Hospital Charge Code |
5106451001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$946.50 |
| Max. Negotiated Rate |
$946.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$946.50
|
|
|
HC INJECTION, ANESTHETIC AGENT, STELLATE GANGLION
|
Facility
|
OP
|
$1,893.00
|
|
|
Service Code
|
CPT 64510
|
| Hospital Charge Code |
5106451001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.32 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,142.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
|
HC INJECTION, ANESTHETIC AGENT, SUPERIOR HYPOGASTRIC PLEXUS
|
Facility
|
IP
|
$2,459.00
|
|
|
Service Code
|
CPT 64517
|
| Hospital Charge Code |
5106451701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,229.50 |
| Max. Negotiated Rate |
$1,229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.50
|
|
|
HC INJECTION, ANESTHETIC AGENT, SUPERIOR HYPOGASTRIC PLEXUS
|
Facility
|
OP
|
$2,459.00
|
|
|
Service Code
|
CPT 64517
|
| Hospital Charge Code |
5106451701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.49 |
| Max. Negotiated Rate |
$1,888.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,087.77
|
| Rate for Payer: Aetna Government |
$1,087.77
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$761.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$761.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$761.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,087.77
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$217.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$184.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,087.77
|
| Rate for Payer: EmblemHealth Commercial |
$250.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$978.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$924.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$968.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,087.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$968.12
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,087.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$477.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$142.49
|
| Rate for Payer: Healthfirst Medicare Advantage |
$924.60
|
| Rate for Payer: Healthfirst QHP |
$1,087.77
|
| Rate for Payer: Humana Medicare |
$1,109.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,142.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,087.77
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,087.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,087.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,033.38
|
| Rate for Payer: Wellcare Medicare |
$1,033.38
|
|
