|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
OP
|
$1,550.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
5101104601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$686.50 |
| Max. Negotiated Rate |
$1,472.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,472.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,388.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$686.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,388.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$933.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,317.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,255.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$697.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,232.25
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$1,240.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,240.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,240.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$697.50
|
| Rate for Payer: Multiplan Commercial |
$1,441.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,317.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$697.50
|
| Rate for Payer: United Healthcare Commercial |
$1,472.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$697.50
|
| Rate for Payer: United Healthcare VA CCN |
$697.50
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
IP
|
$1,550.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
5101104601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,147.15 |
| Max. Negotiated Rate |
$1,472.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,472.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,147.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,147.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,317.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,302.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,240.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$1,240.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,240.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,240.00
|
| Rate for Payer: Multiplan Commercial |
$1,441.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,317.50
|
| Rate for Payer: United Healthcare Commercial |
$1,472.50
|
|
|
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
|
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
|
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 MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104301
|
|
Hospital Revenue Code
|
981
|
| 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 MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104302
|
|
Hospital Revenue Code
|
981
|
| 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 MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104301
|
|
Hospital Revenue Code
|
981
|
| 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 MUSCLE & FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104302
|
|
Hospital Revenue Code
|
981
|
| 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 MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$770.05
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
4501104301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$341.06 |
| Max. Negotiated Rate |
$731.55 |
| Rate for Payer: Aetna of VT Commercial |
$731.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$689.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$341.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$689.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$463.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$654.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$623.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$346.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$612.19
|
| Rate for Payer: Cash Price |
$385.02
|
| Rate for Payer: Cigna Commercial |
$616.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$616.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$616.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$346.52
|
| Rate for Payer: Multiplan Commercial |
$716.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$654.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$346.52
|
| Rate for Payer: United Healthcare Commercial |
$731.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$346.52
|
| Rate for Payer: United Healthcare VA CCN |
$346.52
|
|
|
DEB MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$770.05
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
4501104301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$569.91 |
| Max. Negotiated Rate |
$731.55 |
| Rate for Payer: Aetna of VT Commercial |
$731.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$569.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$569.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$654.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$646.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$616.04
|
| Rate for Payer: Cash Price |
$385.02
|
| Rate for Payer: Cigna Commercial |
$616.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$616.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$616.04
|
| Rate for Payer: Multiplan Commercial |
$716.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$654.54
|
| Rate for Payer: United Healthcare Commercial |
$731.55
|
|
|
DEB MUSCLE & FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104302
|
|
Hospital Revenue Code
|
981
|
| 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 MUSCLE & FASCIA 20 SQ CM/<
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
9811104301
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
IP
|
$2,575.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,905.76 |
| Max. Negotiated Rate |
$2,446.25 |
| Rate for Payer: Aetna of VT Commercial |
$2,446.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,905.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,905.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,188.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,163.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,060.00
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,060.00
|
| Rate for Payer: Multiplan Commercial |
$2,394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,188.75
|
| Rate for Payer: United Healthcare Commercial |
$2,446.25
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
5101104701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$762.30 |
| Max. Negotiated Rate |
$978.50 |
| Rate for Payer: Aetna of VT Commercial |
$978.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$762.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$762.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$875.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$865.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$824.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$824.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$824.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$824.00
|
| Rate for Payer: Multiplan Commercial |
$957.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$875.50
|
| Rate for Payer: United Healthcare Commercial |
$978.50
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
OP
|
$1,545.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$684.28 |
| Max. Negotiated Rate |
$1,467.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,467.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,384.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$684.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,384.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$930.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,313.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,251.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$695.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,228.28
|
| Rate for Payer: Cash Price |
$772.50
|
| Rate for Payer: Cigna Commercial |
$1,236.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,236.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,236.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$695.25
|
| Rate for Payer: Multiplan Commercial |
$1,436.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,313.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$695.25
|
| Rate for Payer: United Healthcare Commercial |
$1,467.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$695.25
|
| Rate for Payer: United Healthcare VA CCN |
$695.25
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
IP
|
$1,545.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,143.45 |
| Max. Negotiated Rate |
$1,467.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,467.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,143.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,143.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,313.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,297.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,236.00
|
| Rate for Payer: Cash Price |
$772.50
|
| Rate for Payer: Cigna Commercial |
$1,236.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,236.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,236.00
|
| Rate for Payer: Multiplan Commercial |
$1,436.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,313.25
|
| Rate for Payer: United Healthcare Commercial |
$1,467.75
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Professional
|
Both
|
$2,575.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.86 |
| Max. Negotiated Rate |
$2,420.50 |
| Rate for Payer: Aetna of VT Commercial |
$2,420.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$101.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$145.10
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$99.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$186.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$186.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.63
|
| Rate for Payer: Multiplan Commercial |
$2,394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare Commercial |
$135.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare VA CCN |
$87.86
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
5101104701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$456.19 |
| Max. Negotiated Rate |
$978.50 |
| Rate for Payer: Aetna of VT Commercial |
$978.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$922.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$456.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$922.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$620.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$875.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$834.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$463.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$818.85
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$824.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$824.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$824.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$463.50
|
| Rate for Payer: Multiplan Commercial |
$957.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$875.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$463.50
|
| Rate for Payer: United Healthcare Commercial |
$978.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$463.50
|
| Rate for Payer: United Healthcare VA CCN |
$463.50
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
5101104701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.86 |
| Max. Negotiated Rate |
$968.20 |
| Rate for Payer: Aetna of VT Commercial |
$968.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$922.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$922.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$101.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$145.10
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$99.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$186.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$186.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.63
|
| Rate for Payer: Multiplan Commercial |
$957.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare Commercial |
$135.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare VA CCN |
$87.86
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Professional
|
Both
|
$1,545.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.86 |
| Max. Negotiated Rate |
$1,452.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,452.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,384.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,384.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$145.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$101.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$145.10
|
| Rate for Payer: Cash Price |
$772.50
|
| Rate for Payer: Cash Price |
$772.50
|
| Rate for Payer: Cigna Commercial |
$99.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$186.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$186.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.63
|
| Rate for Payer: Multiplan Commercial |
$1,436.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare Commercial |
$135.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.86
|
| Rate for Payer: United Healthcare VA CCN |
$87.86
|
|
|
DEBRID BONE EACH ADDT'L 20 SQ
|
Facility
|
OP
|
$2,575.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
9601104701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,140.47 |
| Max. Negotiated Rate |
$2,446.25 |
| Rate for Payer: Aetna of VT Commercial |
$2,446.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,140.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,550.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,188.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,085.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,158.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,047.12
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,060.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,158.75
|
| Rate for Payer: Multiplan Commercial |
$2,394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,188.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,158.75
|
| Rate for Payer: United Healthcare Commercial |
$2,446.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,158.75
|
| Rate for Payer: United Healthcare VA CCN |
$1,158.75
|
|
|
DEBRIDE GENITALIA & PERINEUM
|
Facility
|
OP
|
$1,213.00
|
|
|
Service Code
|
CPT 11004
|
| Hospital Charge Code |
5101100401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$537.24 |
| Max. Negotiated Rate |
$1,152.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,152.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,086.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$537.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,086.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$730.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,031.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$982.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$545.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$964.34
|
| Rate for Payer: Cash Price |
$606.50
|
| Rate for Payer: Cigna Commercial |
$970.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$970.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$970.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$545.85
|
| Rate for Payer: Multiplan Commercial |
$1,128.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,031.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$545.85
|
| Rate for Payer: United Healthcare Commercial |
$1,152.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$545.85
|
| Rate for Payer: United Healthcare VA CCN |
$545.85
|
|
|
DEBRIDE GENITALIA & PERINEUM
|
Facility
|
IP
|
$1,213.00
|
|
|
Service Code
|
CPT 11004
|
| Hospital Charge Code |
5101100401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$897.74 |
| Max. Negotiated Rate |
$1,152.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,152.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$897.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$897.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,031.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,018.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$970.40
|
| Rate for Payer: Cash Price |
$606.50
|
| Rate for Payer: Cigna Commercial |
$970.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$970.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$970.40
|
| Rate for Payer: Multiplan Commercial |
$1,128.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,031.05
|
| Rate for Payer: United Healthcare Commercial |
$1,152.35
|
|
|
DEBRIDE GENITALIA & PERINEUM
|
Professional
|
Both
|
$1,478.00
|
|
|
Service Code
|
CPT 11004
|
| Hospital Charge Code |
9601100402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$513.94 |
| Max. Negotiated Rate |
$1,389.32 |
| Rate for Payer: Aetna of VT Commercial |
$1,389.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,324.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$529.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,324.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$719.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$886.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$886.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$591.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$886.49
|
| Rate for Payer: Cash Price |
$739.00
|
| Rate for Payer: Cash Price |
$739.00
|
| Rate for Payer: Cigna Commercial |
$578.89
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$869.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$869.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$513.95
|
| Rate for Payer: Multiplan Commercial |
$1,374.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$729.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$513.94
|
| Rate for Payer: United Healthcare Commercial |
$790.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$513.94
|
| Rate for Payer: United Healthcare VA CCN |
$513.94
|
|
