|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Facility
|
IP
|
$1,946.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
9602407302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,440.23 |
| Max. Negotiated Rate |
$1,848.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,848.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,440.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,440.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,654.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,634.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,556.80
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cigna Commercial |
$1,556.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,556.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,556.80
|
| Rate for Payer: Multiplan Commercial |
$1,809.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,654.10
|
| Rate for Payer: United Healthcare Commercial |
$1,848.70
|
|
|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Professional
|
Both
|
$6,453.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
9602407301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$648.18 |
| Max. Negotiated Rate |
$6,065.82 |
| Rate for Payer: Aetna of VT Commercial |
$6,065.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,781.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$667.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,781.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$907.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$818.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$818.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$745.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$818.81
|
| Rate for Payer: Cash Price |
$3,226.50
|
| Rate for Payer: Cash Price |
$3,226.50
|
| Rate for Payer: Cigna Commercial |
$1,226.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,089.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,089.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$648.18
|
| Rate for Payer: Multiplan Commercial |
$6,001.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$920.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$648.18
|
| Rate for Payer: United Healthcare Commercial |
$997.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$648.18
|
| Rate for Payer: United Healthcare VA CCN |
$648.18
|
|
|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Facility
|
OP
|
$4,507.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
5102407301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,996.15 |
| Max. Negotiated Rate |
$4,281.65 |
| Rate for Payer: Aetna of VT Commercial |
$4,281.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,037.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,996.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,037.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,713.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,830.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,650.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,028.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,583.07
|
| Rate for Payer: Cash Price |
$2,253.50
|
| Rate for Payer: Cigna Commercial |
$3,605.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,605.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,605.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,028.15
|
| Rate for Payer: Multiplan Commercial |
$4,191.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,830.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,028.15
|
| Rate for Payer: United Healthcare Commercial |
$4,281.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,028.15
|
| Rate for Payer: United Healthcare VA CCN |
$2,028.15
|
|
|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Facility
|
IP
|
$4,507.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
5102407301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,335.63 |
| Max. Negotiated Rate |
$4,281.65 |
| Rate for Payer: Aetna of VT Commercial |
$4,281.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,335.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,335.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,830.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,785.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,605.60
|
| Rate for Payer: Cash Price |
$2,253.50
|
| Rate for Payer: Cigna Commercial |
$3,605.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,605.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,605.60
|
| Rate for Payer: Multiplan Commercial |
$4,191.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,830.95
|
| Rate for Payer: United Healthcare Commercial |
$4,281.65
|
|
|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Professional
|
Both
|
$1,946.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
9822407301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$648.18 |
| Max. Negotiated Rate |
$1,829.24 |
| Rate for Payer: Aetna of VT Commercial |
$1,829.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,743.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$667.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,743.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$907.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$818.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$818.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$745.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$818.81
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cigna Commercial |
$1,226.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,089.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,089.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$648.18
|
| Rate for Payer: Multiplan Commercial |
$1,809.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$920.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$648.18
|
| Rate for Payer: United Healthcare Commercial |
$997.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$648.18
|
| Rate for Payer: United Healthcare VA CCN |
$648.18
|
|
|
EX ARM/ELBOW TUM DEEP 5 CM/>
|
Facility
|
IP
|
$6,453.00
|
|
|
Service Code
|
CPT 24073
|
| Hospital Charge Code |
9602407301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$4,775.87 |
| Max. Negotiated Rate |
$6,130.35 |
| Rate for Payer: Aetna of VT Commercial |
$6,130.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,775.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,775.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,485.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,420.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,162.40
|
| Rate for Payer: Cash Price |
$3,226.50
|
| Rate for Payer: Cigna Commercial |
$5,162.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,162.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,162.40
|
| Rate for Payer: Multiplan Commercial |
$6,001.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,485.05
|
| Rate for Payer: United Healthcare Commercial |
$6,130.35
|
|
|
EXC ABD LES SC < 3 CM
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
CPT 22902
|
| Hospital Charge Code |
9822290201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$542.55 |
| Max. Negotiated Rate |
$1,163.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,163.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,097.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$542.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,097.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$737.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,041.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$992.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$551.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$973.88
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$980.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$980.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$980.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$551.25
|
| Rate for Payer: Multiplan Commercial |
$1,139.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,041.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$551.25
|
| Rate for Payer: United Healthcare Commercial |
$1,163.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$551.25
|
| Rate for Payer: United Healthcare VA CCN |
$551.25
|
|
|
EXC ABD LES SC < 3 CM
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
CPT 22902
|
| Hospital Charge Code |
9822290201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$906.62 |
| Max. Negotiated Rate |
$1,163.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,163.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$906.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$906.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,041.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,029.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$980.00
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$980.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$980.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$980.00
|
| Rate for Payer: Multiplan Commercial |
$1,139.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,041.25
|
| Rate for Payer: United Healthcare Commercial |
$1,163.75
|
|
|
EXC ABD LES SC < 3 CM
|
Professional
|
Both
|
$1,225.00
|
|
|
Service Code
|
CPT 22902
|
| Hospital Charge Code |
9822290201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$314.08 |
| Max. Negotiated Rate |
$1,151.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,151.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,097.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$323.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,097.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$439.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$575.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$575.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$361.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$575.15
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$594.43
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$731.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$731.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$442.24
|
| Rate for Payer: Multiplan Commercial |
$1,139.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$445.99
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$314.08
|
| Rate for Payer: United Healthcare Commercial |
$483.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$314.08
|
| Rate for Payer: United Healthcare VA CCN |
$314.08
|
|
|
EXC ABD LES SC 3 CM/>
|
Facility
|
OP
|
$1,134.00
|
|
|
Service Code
|
CPT 22903
|
| Hospital Charge Code |
9822290301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$502.25 |
| Max. Negotiated Rate |
$1,077.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,077.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,015.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$502.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,015.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$682.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$963.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$918.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$510.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$901.53
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna Commercial |
$907.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$907.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$907.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$510.30
|
| Rate for Payer: Multiplan Commercial |
$1,054.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$963.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$510.30
|
| Rate for Payer: United Healthcare Commercial |
$1,077.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$510.30
|
| Rate for Payer: United Healthcare VA CCN |
$510.30
|
|
|
EXC ABD LES SC 3 CM/>
|
Facility
|
IP
|
$1,134.00
|
|
|
Service Code
|
CPT 22903
|
| Hospital Charge Code |
9822290301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$839.27 |
| Max. Negotiated Rate |
$1,077.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,077.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$839.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$839.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$963.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$952.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$907.20
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna Commercial |
$907.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$907.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$907.20
|
| Rate for Payer: Multiplan Commercial |
$1,054.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$963.90
|
| Rate for Payer: United Healthcare Commercial |
$1,077.30
|
|
|
EXC ABD LES SC 3 CM/>
|
Professional
|
Both
|
$1,134.00
|
|
|
Service Code
|
CPT 22903
|
| Hospital Charge Code |
9822290301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$409.96 |
| Max. Negotiated Rate |
$1,065.96 |
| Rate for Payer: Aetna of VT Commercial |
$1,065.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,015.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$422.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,015.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$573.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$519.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$471.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$519.81
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Cigna Commercial |
$776.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$692.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$692.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$409.96
|
| Rate for Payer: Multiplan Commercial |
$1,054.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$582.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$409.97
|
| Rate for Payer: United Healthcare Commercial |
$630.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$409.97
|
| Rate for Payer: United Healthcare VA CCN |
$409.97
|
|
|
EXC ABD TUM 5 CM OR LESS
|
Professional
|
Both
|
$3,285.00
|
|
|
Service Code
|
CPT 49203
|
| Hospital Charge Code |
9824920301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,314.00 |
| Max. Negotiated Rate |
$3,087.90 |
| Rate for Payer: Aetna of VT Commercial |
$3,087.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,943.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,943.03
|
| Rate for Payer: Cash Price |
$1,642.50
|
| Rate for Payer: Cash Price |
$1,642.50
|
| Rate for Payer: Cigna Commercial |
$2,002.49
|
| Rate for Payer: Multiplan Commercial |
$3,055.05
|
| Rate for Payer: United Healthcare Commercial |
$2,792.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,314.00
|
|
|
EXC ABD TUM 5 CM OR LESS
|
Facility
|
IP
|
$3,285.00
|
|
|
Service Code
|
CPT 49203
|
| Hospital Charge Code |
9824920301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$2,431.23 |
| Max. Negotiated Rate |
$3,120.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,120.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,431.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,431.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,792.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,759.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,628.00
|
| Rate for Payer: Cash Price |
$1,642.50
|
| Rate for Payer: Cigna Commercial |
$2,628.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,628.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,628.00
|
| Rate for Payer: Multiplan Commercial |
$3,055.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,792.25
|
| Rate for Payer: United Healthcare Commercial |
$3,120.75
|
|
|
EXC ABD TUM 5 CM OR LESS
|
Facility
|
OP
|
$3,285.00
|
|
|
Service Code
|
CPT 49203
|
| Hospital Charge Code |
9824920301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,454.93 |
| Max. Negotiated Rate |
$3,120.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,120.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,943.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,454.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,943.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,977.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,792.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,660.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,478.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,611.57
|
| Rate for Payer: Cash Price |
$1,642.50
|
| Rate for Payer: Cigna Commercial |
$2,628.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,628.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,628.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,478.25
|
| Rate for Payer: Multiplan Commercial |
$3,055.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,792.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,478.25
|
| Rate for Payer: United Healthcare Commercial |
$3,120.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,478.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,478.25
|
|
|
EXC ARM/ELBOW LES SC < 3 CM
|
Professional
|
Both
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9822407501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$313.46 |
| Max. Negotiated Rate |
$1,003.92 |
| Rate for Payer: Aetna of VT Commercial |
$1,003.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$956.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$322.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$956.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$438.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$657.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$657.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$360.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$657.59
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cigna Commercial |
$592.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$817.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$817.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$497.83
|
| Rate for Payer: Multiplan Commercial |
$993.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$445.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$313.46
|
| Rate for Payer: United Healthcare Commercial |
$482.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.46
|
| Rate for Payer: United Healthcare VA CCN |
$313.46
|
|
|
EXC ARM/ELBOW LES SC < 3 CM
|
Facility
|
IP
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9822407501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$790.43 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,014.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$790.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$790.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$907.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$897.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$854.40
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cigna Commercial |
$854.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$854.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$854.40
|
| Rate for Payer: Multiplan Commercial |
$993.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$907.80
|
| Rate for Payer: United Healthcare Commercial |
$1,014.60
|
|
|
EXC ARM/ELBOW LES SC < 3 CM
|
Facility
|
OP
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9822407501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$473.02 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,014.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$956.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$473.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$956.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$642.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$907.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$865.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$480.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$849.06
|
| Rate for Payer: Cash Price |
$534.00
|
| Rate for Payer: Cigna Commercial |
$854.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$854.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$854.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$480.60
|
| Rate for Payer: Multiplan Commercial |
$993.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$907.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$480.60
|
| Rate for Payer: United Healthcare Commercial |
$1,014.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$480.60
|
| Rate for Payer: United Healthcare VA CCN |
$480.60
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
IP
|
$7,423.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
5102407101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5,493.76 |
| Max. Negotiated Rate |
$7,051.85 |
| Rate for Payer: Aetna of VT Commercial |
$7,051.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,493.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,493.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,309.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,235.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,938.40
|
| Rate for Payer: Cash Price |
$3,711.50
|
| Rate for Payer: Cigna Commercial |
$5,938.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,938.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,938.40
|
| Rate for Payer: Multiplan Commercial |
$6,903.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,309.55
|
| Rate for Payer: United Healthcare Commercial |
$7,051.85
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
OP
|
$8,416.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9602407101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,727.45 |
| Max. Negotiated Rate |
$7,995.20 |
| Rate for Payer: Aetna of VT Commercial |
$7,995.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,539.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,727.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,539.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5,066.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,153.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,816.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,787.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,690.72
|
| Rate for Payer: Cash Price |
$4,208.00
|
| Rate for Payer: Cigna Commercial |
$6,732.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,732.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,732.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,787.20
|
| Rate for Payer: Multiplan Commercial |
$7,826.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,153.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,787.20
|
| Rate for Payer: United Healthcare Commercial |
$7,995.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,787.20
|
| Rate for Payer: United Healthcare VA CCN |
$3,787.20
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Professional
|
Both
|
$993.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9822407101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$380.72 |
| Max. Negotiated Rate |
$933.42 |
| Rate for Payer: Aetna of VT Commercial |
$933.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$889.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$392.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$889.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$533.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$480.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$480.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$437.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$480.69
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cigna Commercial |
$720.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$639.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$639.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$380.73
|
| Rate for Payer: Multiplan Commercial |
$923.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$540.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$380.72
|
| Rate for Payer: United Healthcare Commercial |
$585.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.72
|
| Rate for Payer: United Healthcare VA CCN |
$380.72
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
IP
|
$993.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9822407101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$734.92 |
| Max. Negotiated Rate |
$943.35 |
| Rate for Payer: Aetna of VT Commercial |
$943.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$734.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$734.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$844.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$834.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$794.40
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cigna Commercial |
$794.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$794.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$794.40
|
| Rate for Payer: Multiplan Commercial |
$923.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$844.05
|
| Rate for Payer: United Healthcare Commercial |
$943.35
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Professional
|
Both
|
$8,416.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9602407101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$380.72 |
| Max. Negotiated Rate |
$7,911.04 |
| Rate for Payer: Aetna of VT Commercial |
$7,911.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,539.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$392.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,539.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$533.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$480.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$480.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$437.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$480.69
|
| Rate for Payer: Cash Price |
$4,208.00
|
| Rate for Payer: Cash Price |
$4,208.00
|
| Rate for Payer: Cigna Commercial |
$720.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$639.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$639.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$380.73
|
| Rate for Payer: Multiplan Commercial |
$7,826.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$540.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$380.72
|
| Rate for Payer: United Healthcare Commercial |
$585.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.72
|
| Rate for Payer: United Healthcare VA CCN |
$380.72
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
OP
|
$993.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9602407102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$439.80 |
| Max. Negotiated Rate |
$943.35 |
| Rate for Payer: Aetna of VT Commercial |
$943.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$889.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$439.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$889.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$597.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$844.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$804.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$446.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$789.43
|
| Rate for Payer: Cash Price |
$496.50
|
| Rate for Payer: Cigna Commercial |
$794.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$794.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$794.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$446.85
|
| Rate for Payer: Multiplan Commercial |
$923.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$844.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$446.85
|
| Rate for Payer: United Healthcare Commercial |
$943.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$446.85
|
| Rate for Payer: United Healthcare VA CCN |
$446.85
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
OP
|
$7,423.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
5102407101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,287.65 |
| Max. Negotiated Rate |
$7,051.85 |
| Rate for Payer: Aetna of VT Commercial |
$7,051.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,650.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,287.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,650.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4,468.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,309.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,012.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,340.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,901.28
|
| Rate for Payer: Cash Price |
$3,711.50
|
| Rate for Payer: Cigna Commercial |
$5,938.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,938.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,938.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,340.35
|
| Rate for Payer: Multiplan Commercial |
$6,903.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,309.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,340.35
|
| Rate for Payer: United Healthcare Commercial |
$7,051.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,340.35
|
| Rate for Payer: United Healthcare VA CCN |
$3,340.35
|
|
