|
DEB BONE 20 SQ CM/<
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9821104401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$769.70 |
| Max. Negotiated Rate |
$988.00 |
| Rate for Payer: Aetna of VT Commercial |
$988.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$884.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$873.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$832.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.00
|
| Rate for Payer: Multiplan Commercial |
$967.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$884.00
|
| Rate for Payer: United Healthcare Commercial |
$988.00
|
|
|
DEB BONE 20 SQ CM/<
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9811104401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$207.26 |
| Max. Negotiated Rate |
$977.60 |
| Rate for Payer: Aetna of VT Commercial |
$977.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$931.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$213.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$931.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$290.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$466.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$466.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$466.57
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$233.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$478.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$478.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$290.14
|
| Rate for Payer: Multiplan Commercial |
$967.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.26
|
| Rate for Payer: United Healthcare Commercial |
$318.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.26
|
| Rate for Payer: United Healthcare VA CCN |
$207.26
|
|
|
DEB BONE 20 SQ CM/<
|
Professional
|
Both
|
$4,365.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
5101104401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.26 |
| Max. Negotiated Rate |
$4,103.10 |
| Rate for Payer: Aetna of VT Commercial |
$4,103.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,910.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$213.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,910.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$290.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$466.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$466.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$466.57
|
| Rate for Payer: Cash Price |
$2,182.50
|
| Rate for Payer: Cash Price |
$2,182.50
|
| Rate for Payer: Cigna Commercial |
$233.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$478.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$478.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$290.14
|
| Rate for Payer: Multiplan Commercial |
$4,059.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.26
|
| Rate for Payer: United Healthcare Commercial |
$318.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.26
|
| Rate for Payer: United Healthcare VA CCN |
$207.26
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
OP
|
$5,404.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9601104401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,393.43 |
| Max. Negotiated Rate |
$5,133.80 |
| Rate for Payer: Aetna of VT Commercial |
$5,133.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,841.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,393.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,841.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,253.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,593.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,377.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,431.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,296.18
|
| Rate for Payer: Cash Price |
$2,702.00
|
| Rate for Payer: Cigna Commercial |
$4,323.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,323.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,323.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,431.80
|
| Rate for Payer: Multiplan Commercial |
$5,025.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,593.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,431.80
|
| Rate for Payer: United Healthcare Commercial |
$5,133.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,431.80
|
| Rate for Payer: United Healthcare VA CCN |
$2,431.80
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9811104401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$769.70 |
| Max. Negotiated Rate |
$988.00 |
| Rate for Payer: Aetna of VT Commercial |
$988.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$884.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$873.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$832.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.00
|
| Rate for Payer: Multiplan Commercial |
$967.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$884.00
|
| Rate for Payer: United Healthcare Commercial |
$988.00
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
OP
|
$1,040.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9811104402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$460.62 |
| Max. Negotiated Rate |
$988.00 |
| Rate for Payer: Aetna of VT Commercial |
$988.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$931.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$460.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$931.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$626.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$884.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$842.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$468.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$826.80
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$967.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$884.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$468.00
|
| Rate for Payer: United Healthcare Commercial |
$988.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$468.00
|
| Rate for Payer: United Healthcare VA CCN |
$468.00
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
IP
|
$5,404.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9601104401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,999.50 |
| Max. Negotiated Rate |
$5,133.80 |
| Rate for Payer: Aetna of VT Commercial |
$5,133.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,999.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,999.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,593.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,539.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,323.20
|
| Rate for Payer: Cash Price |
$2,702.00
|
| Rate for Payer: Cigna Commercial |
$4,323.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,323.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,323.20
|
| Rate for Payer: Multiplan Commercial |
$5,025.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,593.40
|
| Rate for Payer: United Healthcare Commercial |
$5,133.80
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
IP
|
$4,365.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
5101104401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,230.54 |
| Max. Negotiated Rate |
$4,146.75 |
| Rate for Payer: Aetna of VT Commercial |
$4,146.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,230.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,230.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,710.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,666.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,492.00
|
| Rate for Payer: Cash Price |
$2,182.50
|
| Rate for Payer: Cigna Commercial |
$3,492.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,492.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,492.00
|
| Rate for Payer: Multiplan Commercial |
$4,059.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,710.25
|
| Rate for Payer: United Healthcare Commercial |
$4,146.75
|
|
|
DEB BONE 20 SQ CM/<
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
9811104402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$769.70 |
| Max. Negotiated Rate |
$988.00 |
| Rate for Payer: Aetna of VT Commercial |
$988.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$769.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$884.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$873.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$832.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.00
|
| Rate for Payer: Multiplan Commercial |
$967.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$884.00
|
| Rate for Payer: United Healthcare Commercial |
$988.00
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$1,270.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.55 |
| Max. Negotiated Rate |
$1,193.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,193.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,137.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$146.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,137.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$163.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$357.37
|
| Rate for Payer: Cash Price |
$635.00
|
| Rate for Payer: Cash Price |
$635.00
|
| Rate for Payer: Cigna Commercial |
$160.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$358.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$358.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$1,181.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare Commercial |
$219.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare VA CCN |
$142.55
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.55 |
| Max. Negotiated Rate |
$470.00 |
| Rate for Payer: Aetna of VT Commercial |
$470.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$146.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$163.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$357.37
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$160.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$358.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$358.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare Commercial |
$219.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare VA CCN |
$142.55
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$370.05 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$420.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$400.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9821104301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$221.45 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$221.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$301.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$405.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$225.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$397.50
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare VA CCN |
$225.00
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$1,270.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$562.48 |
| Max. Negotiated Rate |
$1,206.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,206.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,137.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$562.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,137.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$764.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,079.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,028.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$571.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,009.65
|
| Rate for Payer: Cash Price |
$635.00
|
| Rate for Payer: Cigna Commercial |
$1,016.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,016.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,016.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$571.50
|
| Rate for Payer: Multiplan Commercial |
$1,181.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,079.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$571.50
|
| Rate for Payer: United Healthcare Commercial |
$1,206.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$571.50
|
| Rate for Payer: United Healthcare VA CCN |
$571.50
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$771.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
5101104301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$570.62 |
| Max. Negotiated Rate |
$732.45 |
| Rate for Payer: Aetna of VT Commercial |
$732.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$570.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$570.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$655.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$647.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$616.80
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$616.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$616.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$616.80
|
| Rate for Payer: Multiplan Commercial |
$717.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$655.35
|
| Rate for Payer: United Healthcare Commercial |
$732.45
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9821104301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$142.55 |
| Max. Negotiated Rate |
$470.00 |
| Rate for Payer: Aetna of VT Commercial |
$470.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$146.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$163.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$357.37
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$160.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$358.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$358.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare Commercial |
$219.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare VA CCN |
$142.55
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9821104301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$370.05 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$420.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$400.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$1,270.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$939.93 |
| Max. Negotiated Rate |
$1,206.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,206.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$939.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$939.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,079.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,066.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,016.00
|
| Rate for Payer: Cash Price |
$635.00
|
| Rate for Payer: Cigna Commercial |
$1,016.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,016.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,016.00
|
| Rate for Payer: Multiplan Commercial |
$1,181.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,079.50
|
| Rate for Payer: United Healthcare Commercial |
$1,206.50
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$771.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
5101104301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$341.48 |
| Max. Negotiated Rate |
$732.45 |
| Rate for Payer: Aetna of VT Commercial |
$732.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$341.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$464.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$655.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$624.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$346.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$612.95
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$616.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$616.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$616.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$346.95
|
| Rate for Payer: Multiplan Commercial |
$717.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$655.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$346.95
|
| Rate for Payer: United Healthcare Commercial |
$732.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$346.95
|
| Rate for Payer: United Healthcare VA CCN |
$346.95
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9601104302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$221.45 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$221.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$301.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$405.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$225.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$397.50
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare VA CCN |
$225.00
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$771.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
5101104301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.55 |
| Max. Negotiated Rate |
$724.74 |
| Rate for Payer: Aetna of VT Commercial |
$724.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$146.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$163.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$357.37
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$160.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$358.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$358.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$717.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare Commercial |
$219.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.55
|
| Rate for Payer: United Healthcare VA CCN |
$142.55
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
9601104601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,327.74 |
| Max. Negotiated Rate |
$1,704.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,704.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,327.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,327.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,524.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,506.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,435.20
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,435.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,435.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,435.20
|
| Rate for Payer: Multiplan Commercial |
$1,668.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,524.90
|
| Rate for Payer: United Healthcare Commercial |
$1,704.30
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
9601104601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$794.56 |
| Max. Negotiated Rate |
$1,704.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,704.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,607.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$794.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,607.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,079.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,524.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,453.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$807.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,426.23
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,435.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,435.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,435.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$807.30
|
| Rate for Payer: Multiplan Commercial |
$1,668.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,524.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$807.30
|
| Rate for Payer: United Healthcare Commercial |
$1,704.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$807.30
|
| Rate for Payer: United Healthcare VA CCN |
$807.30
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
9601104602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$181.32 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna of VT Commercial |
$232.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$181.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$181.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$208.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$205.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.00
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$196.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$196.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$196.00
|
| Rate for Payer: Multiplan Commercial |
$227.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$208.25
|
| Rate for Payer: United Healthcare Commercial |
$232.75
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Professional
|
Both
|
$1,794.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
9601104601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$1,686.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,686.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,607.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,607.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.92
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$56.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$112.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$112.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.49
|
| Rate for Payer: Multiplan Commercial |
$1,668.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$70.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$76.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.50
|
| Rate for Payer: United Healthcare VA CCN |
$49.50
|
|
