|
DEB SUBQ TISSUE 20 SQ CM/<
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
9821104201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$137.66 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna of VT Commercial |
$176.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$137.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$137.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$156.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.80
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$148.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$148.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$148.80
|
| Rate for Payer: Multiplan Commercial |
$172.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.10
|
| Rate for Payer: United Healthcare Commercial |
$176.70
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
9601104201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$274.58 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Aetna of VT Commercial |
$352.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$274.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$274.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$315.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$311.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$296.80
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$296.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$296.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$296.80
|
| Rate for Payer: Multiplan Commercial |
$345.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$315.35
|
| Rate for Payer: United Healthcare Commercial |
$352.45
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
9811104201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$56.69 |
| Max. Negotiated Rate |
$199.04 |
| Rate for Payer: Aetna of VT Commercial |
$174.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$65.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$159.20
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$63.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.54
|
| Rate for Payer: Multiplan Commercial |
$172.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$56.69
|
| Rate for Payer: United Healthcare Commercial |
$87.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.69
|
| Rate for Payer: United Healthcare VA CCN |
$56.69
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
9601104202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$82.38 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna of VT Commercial |
$176.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$111.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$150.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$147.87
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$148.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$148.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$148.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$83.70
|
| Rate for Payer: Multiplan Commercial |
$172.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$83.70
|
| Rate for Payer: United Healthcare Commercial |
$176.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.70
|
| Rate for Payer: United Healthcare VA CCN |
$83.70
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
9811104202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$56.69 |
| Max. Negotiated Rate |
$199.04 |
| Rate for Payer: Aetna of VT Commercial |
$174.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$65.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$159.20
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$63.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.54
|
| Rate for Payer: Multiplan Commercial |
$172.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$56.69
|
| Rate for Payer: United Healthcare Commercial |
$87.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.69
|
| Rate for Payer: United Healthcare VA CCN |
$56.69
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Professional
|
Both
|
$1,215.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
5101104501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$1,142.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,142.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,088.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,088.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.05
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$26.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.26
|
| Rate for Payer: Multiplan Commercial |
$1,129.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare Commercial |
$35.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare VA CCN |
$22.81
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$85.54 |
| Rate for Payer: Aetna of VT Commercial |
$85.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.05
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$26.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.26
|
| Rate for Payer: Multiplan Commercial |
$84.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare Commercial |
$35.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare VA CCN |
$22.81
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
IP
|
$1,306.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$966.57 |
| Max. Negotiated Rate |
$1,240.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,240.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$966.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$966.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,110.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,097.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,044.80
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$1,044.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,044.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,044.80
|
| Rate for Payer: Multiplan Commercial |
$1,214.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,110.10
|
| Rate for Payer: United Healthcare Commercial |
$1,240.70
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
OP
|
$1,306.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$578.43 |
| Max. Negotiated Rate |
$1,240.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,240.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$578.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$786.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,110.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,057.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$587.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,038.27
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$1,044.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,044.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,044.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$587.70
|
| Rate for Payer: Multiplan Commercial |
$1,214.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,110.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$587.70
|
| Rate for Payer: United Healthcare Commercial |
$1,240.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$587.70
|
| Rate for Payer: United Healthcare VA CCN |
$587.70
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
IP
|
$1,215.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
5101104501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$899.22 |
| Max. Negotiated Rate |
$1,154.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,154.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$899.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$899.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,032.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,020.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$972.00
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$972.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$972.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$972.00
|
| Rate for Payer: Multiplan Commercial |
$1,129.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,032.75
|
| Rate for Payer: United Healthcare Commercial |
$1,154.25
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
OP
|
$1,215.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
5101104501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$538.12 |
| Max. Negotiated Rate |
$1,154.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,154.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,088.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$538.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,088.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$731.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,032.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$984.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$546.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$965.92
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$972.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$972.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$972.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$546.75
|
| Rate for Payer: Multiplan Commercial |
$1,129.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,032.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$546.75
|
| Rate for Payer: United Healthcare Commercial |
$1,154.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$546.75
|
| Rate for Payer: United Healthcare VA CCN |
$546.75
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Aetna of VT Commercial |
$86.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$77.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.80
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$72.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.80
|
| Rate for Payer: Multiplan Commercial |
$84.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.35
|
| Rate for Payer: United Healthcare Commercial |
$86.45
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$40.30 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Aetna of VT Commercial |
$86.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$40.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$77.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$73.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.34
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$72.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.95
|
| Rate for Payer: Multiplan Commercial |
$84.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.95
|
| Rate for Payer: United Healthcare Commercial |
$86.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.95
|
| Rate for Payer: United Healthcare VA CCN |
$40.95
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Professional
|
Both
|
$1,306.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
9601104501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$1,227.64 |
| Rate for Payer: Aetna of VT Commercial |
$1,227.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.05
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$26.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.26
|
| Rate for Payer: Multiplan Commercial |
$1,214.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare Commercial |
$35.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.81
|
| Rate for Payer: United Healthcare VA CCN |
$22.81
|
|
|
DECALCIFICATION PROCEDURE
|
Facility
|
IP
|
$137.03
|
|
|
Service Code
|
CPT 88311
|
| Hospital Charge Code |
3008831101
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$101.42 |
| Max. Negotiated Rate |
$130.18 |
| Rate for Payer: Aetna of VT Commercial |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$101.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$101.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$116.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$115.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$109.62
|
| Rate for Payer: Cash Price |
$68.52
|
| Rate for Payer: Cigna Commercial |
$109.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$109.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$109.62
|
| Rate for Payer: Multiplan Commercial |
$127.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.48
|
| Rate for Payer: United Healthcare Commercial |
$130.18
|
|
|
DECALCIFICATION PROCEDURE
|
Facility
|
OP
|
$137.03
|
|
|
Service Code
|
CPT 88311
|
| Hospital Charge Code |
3008831101
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$130.18 |
| Rate for Payer: Aetna of VT Commercial |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$60.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$82.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$116.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$110.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$61.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.94
|
| Rate for Payer: Cash Price |
$68.52
|
| Rate for Payer: Cash Price |
$68.52
|
| Rate for Payer: Cigna Commercial |
$109.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$109.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$109.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.66
|
| Rate for Payer: Multiplan Commercial |
$127.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$61.66
|
| Rate for Payer: United Healthcare Commercial |
$130.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.34
|
| Rate for Payer: United Healthcare VA CCN |
$61.66
|
|
|
DECALCIFICATION PROCEDURE
|
Professional
|
Both
|
$137.03
|
|
|
Service Code
|
CPT 88311
|
| Hospital Charge Code |
3008831101
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$19.34 |
| Max. Negotiated Rate |
$128.81 |
| Rate for Payer: Aetna of VT Commercial |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$19.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$27.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$28.18
|
| Rate for Payer: Cash Price |
$68.52
|
| Rate for Payer: Cash Price |
$68.52
|
| Rate for Payer: Cigna Commercial |
$25.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$19.34
|
| Rate for Payer: Multiplan Commercial |
$127.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.34
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$19.34
|
| Rate for Payer: United Healthcare Commercial |
$29.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.34
|
| Rate for Payer: United Healthcare VA CCN |
$19.34
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
IP
|
$429.38
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
4503659301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$317.78 |
| Max. Negotiated Rate |
$407.91 |
| Rate for Payer: Aetna of VT Commercial |
$407.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$317.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$317.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$364.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$360.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$343.50
|
| Rate for Payer: Cash Price |
$214.69
|
| Rate for Payer: Cigna Commercial |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$343.50
|
| Rate for Payer: Multiplan Commercial |
$399.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$364.97
|
| Rate for Payer: United Healthcare Commercial |
$407.91
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9823659301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$192.66 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$192.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$261.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$352.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$195.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$345.82
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare VA CCN |
$195.75
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9813659302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$192.66 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$192.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$261.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$352.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$195.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$345.82
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare VA CCN |
$195.75
|
|
|
DECLOT VASCULAR DEVICE
|
Professional
|
Both
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9823659301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$33.10 |
| Max. Negotiated Rate |
$408.90 |
| Rate for Payer: Aetna of VT Commercial |
$408.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$40.02
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$60.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.10
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.10
|
| Rate for Payer: United Healthcare Commercial |
$50.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.10
|
| Rate for Payer: United Healthcare VA CCN |
$33.10
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9813659302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$321.94 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$348.00
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$429.38
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
4503659301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$190.17 |
| Max. Negotiated Rate |
$407.91 |
| Rate for Payer: Aetna of VT Commercial |
$407.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$384.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$384.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$258.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$364.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$193.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$341.36
|
| Rate for Payer: Cash Price |
$214.69
|
| Rate for Payer: Cigna Commercial |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$343.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$193.22
|
| Rate for Payer: Multiplan Commercial |
$399.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$364.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$193.22
|
| Rate for Payer: United Healthcare Commercial |
$407.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.22
|
| Rate for Payer: United Healthcare VA CCN |
$193.22
|
|
|
DECLOT VASCULAR DEVICE
|
Professional
|
Both
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9813659301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$33.10 |
| Max. Negotiated Rate |
$408.90 |
| Rate for Payer: Aetna of VT Commercial |
$408.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$40.02
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$60.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.10
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.10
|
| Rate for Payer: United Healthcare Commercial |
$50.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.10
|
| Rate for Payer: United Healthcare VA CCN |
$33.10
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9823659301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$321.94 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$348.00
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
|
