|
DESTRUCTION PENIS LESION(S)
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
9605405002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.25 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: Aetna of VT Commercial |
$187.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$176.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$176.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$167.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$88.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$156.62
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cigna Commercial |
$157.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$157.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$157.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$88.65
|
| Rate for Payer: Multiplan Commercial |
$183.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$167.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$88.65
|
| Rate for Payer: United Healthcare Commercial |
$187.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.65
|
| Rate for Payer: United Healthcare VA CCN |
$88.65
|
|
|
DESTRUCTION PENIS LESION(S)
|
Facility
|
OP
|
$686.00
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
9605405001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$303.83 |
| Max. Negotiated Rate |
$651.70 |
| Rate for Payer: Aetna of VT Commercial |
$651.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$614.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$303.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$614.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$412.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$583.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$555.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$308.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$545.37
|
| Rate for Payer: Cash Price |
$343.00
|
| Rate for Payer: Cigna Commercial |
$548.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$548.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$548.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$308.70
|
| Rate for Payer: Multiplan Commercial |
$637.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$583.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$308.70
|
| Rate for Payer: United Healthcare Commercial |
$651.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$308.70
|
| Rate for Payer: United Healthcare VA CCN |
$308.70
|
|
|
DESTRUCTION PENIS LESION(S)
|
Facility
|
OP
|
$489.00
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
5105405001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$464.55 |
| Rate for Payer: Aetna of VT Commercial |
$464.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$438.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$216.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$438.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$294.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$415.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$396.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$220.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$388.75
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cigna Commercial |
$391.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$391.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$391.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$220.05
|
| Rate for Payer: Multiplan Commercial |
$454.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$415.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$220.05
|
| Rate for Payer: United Healthcare Commercial |
$464.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$220.05
|
| Rate for Payer: United Healthcare VA CCN |
$220.05
|
|
|
DESTRUCTION PENIS LESION(S)
|
Professional
|
Both
|
$686.00
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
9605405001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.87 |
| Max. Negotiated Rate |
$644.84 |
| Rate for Payer: Aetna of VT Commercial |
$644.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$614.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$105.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$614.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.38
|
| Rate for Payer: Cash Price |
$343.00
|
| Rate for Payer: Cash Price |
$343.00
|
| Rate for Payer: Cigna Commercial |
$178.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$225.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$225.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$637.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare Commercial |
$158.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare VA CCN |
$102.87
|
|
|
DESTRUCTION PENIS LESION(S)
|
Professional
|
Both
|
$489.00
|
|
|
Service Code
|
CPT 54050
|
| Hospital Charge Code |
5105405001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$102.87 |
| Max. Negotiated Rate |
$459.66 |
| Rate for Payer: Aetna of VT Commercial |
$459.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$438.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$105.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$438.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.38
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cigna Commercial |
$178.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$225.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$225.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$454.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare Commercial |
$158.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.87
|
| Rate for Payer: United Healthcare VA CCN |
$102.87
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Aetna of VT Commercial |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.44
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cigna Commercial |
$25.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$25.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$25.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$29.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.40
|
| Rate for Payer: United Healthcare Commercial |
$30.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.40
|
| Rate for Payer: United Healthcare VA CCN |
$14.40
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$42.19 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Aetna of VT Commercial |
$54.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$42.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$42.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$47.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$45.60
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$45.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$45.60
|
| Rate for Payer: Multiplan Commercial |
$53.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.45
|
| Rate for Payer: United Healthcare Commercial |
$54.15
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Aetna of VT Commercial |
$30.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.60
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cigna Commercial |
$25.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$25.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$25.60
|
| Rate for Payer: Multiplan Commercial |
$29.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.20
|
| Rate for Payer: United Healthcare Commercial |
$30.40
|
|
|
DESTRUCT PREMALG LES 2-14
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
5101700301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$24.44 |
| Rate for Payer: Aetna of VT Commercial |
$24.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.01
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna Commercial |
$2.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$10.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$10.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$24.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$2.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare VA CCN |
$1.94
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$25.25 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Aetna of VT Commercial |
$54.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$25.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$45.31
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$45.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$45.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$25.65
|
| Rate for Payer: Multiplan Commercial |
$53.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$25.65
|
| Rate for Payer: United Healthcare Commercial |
$54.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.65
|
| Rate for Payer: United Healthcare VA CCN |
$25.65
|
|
|
DESTRUCT PREMALG LES 2-14
|
Professional
|
Both
|
$57.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna of VT Commercial |
$53.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.01
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$2.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$10.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$10.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$53.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$2.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare VA CCN |
$1.94
|
|
|
DESTRUCT PREMALG LES 2-14
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
9601700302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$30.08 |
| Rate for Payer: Aetna of VT Commercial |
$30.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.01
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cigna Commercial |
$2.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$10.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$10.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.43
|
| Rate for Payer: Multiplan Commercial |
$29.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$2.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.94
|
| Rate for Payer: United Healthcare VA CCN |
$1.94
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
5101700301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna of VT Commercial |
$24.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$15.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$21.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$11.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.67
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna Commercial |
$20.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$20.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$20.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$11.70
|
| Rate for Payer: Multiplan Commercial |
$24.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$11.70
|
| Rate for Payer: United Healthcare Commercial |
$24.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.70
|
| Rate for Payer: United Healthcare VA CCN |
$11.70
|
|
|
DESTRUCT PREMALG LES 2-14
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
5101700301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna of VT Commercial |
$24.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$19.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$19.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$21.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.80
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna Commercial |
$20.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$20.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$20.80
|
| Rate for Payer: Multiplan Commercial |
$24.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.10
|
| Rate for Payer: United Healthcare Commercial |
$24.70
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$113.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$154.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$208.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$115.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$204.31
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$115.65
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare VA CCN |
$115.65
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.86 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna of VT Commercial |
$157.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.80
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.80
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.10
|
| Rate for Payer: United Healthcare Commercial |
$157.70
|
|
|
DESTRUCT PREMALG LESION
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
5101700001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$52.69 |
| Max. Negotiated Rate |
$105.43 |
| 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 |
$54.27
|
| 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 |
$73.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.58
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$59.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$105.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$105.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$65.22
|
| Rate for Payer: Multiplan Commercial |
$84.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare Commercial |
$81.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare VA CCN |
$52.69
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.52 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna of VT Commercial |
$157.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.97
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.70
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.70
|
| Rate for Payer: United Healthcare Commercial |
$157.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.70
|
| Rate for Payer: United Healthcare VA CCN |
$74.70
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$190.21 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.60
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
5101700001
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
DESTRUCT PREMALG LESION
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
5101700001
|
|
Hospital Revenue Code
|
510
|
| 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
|
|
|
DESTRUCT PREMALG LESION
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$52.69 |
| Max. Negotiated Rate |
$156.04 |
| Rate for Payer: Aetna of VT Commercial |
$156.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$54.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$73.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.58
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$59.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$105.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$105.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$65.22
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare Commercial |
$81.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare VA CCN |
$52.69
|
|
|
DESTRUCT PREMALG LESION
|
Professional
|
Both
|
$257.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
9601700001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$52.69 |
| Max. Negotiated Rate |
$241.58 |
| Rate for Payer: Aetna of VT Commercial |
$241.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$54.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$73.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.58
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$59.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$105.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$105.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$65.22
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare Commercial |
$81.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.69
|
| Rate for Payer: United Healthcare VA CCN |
$52.69
|
|
|
DETECT AGENT NOS DNA AMP
|
Facility
|
OP
|
$413.96
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3008779801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$393.26 |
| Rate for Payer: Aetna of VT Commercial |
$393.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$249.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.10
|
| Rate for Payer: Cash Price |
$206.98
|
| Rate for Payer: Cash Price |
$206.98
|
| Rate for Payer: Cigna Commercial |
$331.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.28
|
| Rate for Payer: Multiplan Commercial |
$384.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.28
|
| Rate for Payer: United Healthcare Commercial |
$393.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$186.28
|
|
|
DETECT AGENT NOS DNA AMP
|
Professional
|
Both
|
$413.96
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3008779801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.60 |
| Max. Negotiated Rate |
$389.12 |
| Rate for Payer: Aetna of VT Commercial |
$389.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$59.98
|
| Rate for Payer: Cash Price |
$206.98
|
| Rate for Payer: Cash Price |
$206.98
|
| Rate for Payer: Cigna Commercial |
$42.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.60
|
| Rate for Payer: Multiplan Commercial |
$384.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare Commercial |
$53.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$35.09
|
|
