|
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
|
$993.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9822407101
|
|
Hospital Revenue Code
|
982
|
| 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/>
|
Professional
|
Both
|
$7,423.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
5102407101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$380.72 |
| Max. Negotiated Rate |
$6,977.62 |
| Rate for Payer: Aetna of VT Commercial |
$6,977.62
|
| 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 |
$392.14
|
| 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 |
$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 |
$3,711.50
|
| Rate for Payer: Cash Price |
$3,711.50
|
| 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 |
$6,903.39
|
| 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
|
$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
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Professional
|
Both
|
$993.00
|
|
|
Service Code
|
CPT 24071
|
| Hospital Charge Code |
9602407102
|
|
Hospital Revenue Code
|
960
|
| 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 SUBQ < 3 CM
|
Professional
|
Both
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407502
|
|
Hospital Revenue Code
|
960
|
| 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 SUBQ < 3 CM
|
Facility
|
OP
|
$3,925.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
5102407501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,738.38 |
| Max. Negotiated Rate |
$3,728.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,728.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,516.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,738.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,516.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,362.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,336.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,179.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,766.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,120.38
|
| Rate for Payer: Cash Price |
$1,962.50
|
| Rate for Payer: Cigna Commercial |
$3,140.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,140.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,140.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,766.25
|
| Rate for Payer: Multiplan Commercial |
$3,650.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,336.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,766.25
|
| Rate for Payer: United Healthcare Commercial |
$3,728.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,766.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,766.25
|
|
|
EXC ARM/ELBOW SUBQ < 3 CM
|
Facility
|
OP
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407502
|
|
Hospital Revenue Code
|
960
|
| 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 SUBQ < 3 CM
|
Facility
|
IP
|
$3,925.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
5102407501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,904.89 |
| Max. Negotiated Rate |
$3,728.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,728.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,904.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,904.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,336.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,297.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,140.00
|
| Rate for Payer: Cash Price |
$1,962.50
|
| Rate for Payer: Cigna Commercial |
$3,140.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,140.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,140.00
|
| Rate for Payer: Multiplan Commercial |
$3,650.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,336.25
|
| Rate for Payer: United Healthcare Commercial |
$3,728.75
|
|
|
EXC ARM/ELBOW SUBQ < 3 CM
|
Professional
|
Both
|
$4,992.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$313.46 |
| Max. Negotiated Rate |
$4,692.48 |
| Rate for Payer: Aetna of VT Commercial |
$4,692.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,472.33
|
| 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 |
$4,472.33
|
| 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 |
$2,496.00
|
| Rate for Payer: Cash Price |
$2,496.00
|
| 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 |
$4,642.56
|
| 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 SUBQ < 3 CM
|
Facility
|
IP
|
$4,992.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,694.58 |
| Max. Negotiated Rate |
$4,742.40 |
| Rate for Payer: Aetna of VT Commercial |
$4,742.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,694.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,694.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,243.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,193.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,993.60
|
| Rate for Payer: Cash Price |
$2,496.00
|
| Rate for Payer: Cigna Commercial |
$3,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,993.60
|
| Rate for Payer: Multiplan Commercial |
$4,642.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,243.20
|
| Rate for Payer: United Healthcare Commercial |
$4,742.40
|
|
|
EXC ARM/ELBOW SUBQ < 3 CM
|
Facility
|
OP
|
$4,992.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,210.96 |
| Max. Negotiated Rate |
$4,742.40 |
| Rate for Payer: Aetna of VT Commercial |
$4,742.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,472.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,210.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,472.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,005.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,243.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,043.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,246.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,968.64
|
| Rate for Payer: Cash Price |
$2,496.00
|
| Rate for Payer: Cigna Commercial |
$3,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,993.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,246.40
|
| Rate for Payer: Multiplan Commercial |
$4,642.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,243.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,246.40
|
| Rate for Payer: United Healthcare Commercial |
$4,742.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,246.40
|
| Rate for Payer: United Healthcare VA CCN |
$2,246.40
|
|
|
EXC ARM/ELBOW SUBQ < 3 CM
|
Facility
|
IP
|
$1,068.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
9602407502
|
|
Hospital Revenue Code
|
960
|
| 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 SUBQ < 3 CM
|
Professional
|
Both
|
$3,925.00
|
|
|
Service Code
|
CPT 24075
|
| Hospital Charge Code |
5102407501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$313.46 |
| Max. Negotiated Rate |
$3,689.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,689.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,516.41
|
| 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 |
$3,516.41
|
| 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 |
$1,962.50
|
| Rate for Payer: Cash Price |
$1,962.50
|
| 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 |
$3,650.25
|
| 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 BACK/FLANK SUB1 < 3 CM
|
Facility
|
IP
|
$7,199.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$5,327.98 |
| Max. Negotiated Rate |
$6,839.05 |
| Rate for Payer: Aetna of VT Commercial |
$6,839.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,327.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,327.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,119.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,047.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,759.20
|
| Rate for Payer: Cash Price |
$3,599.50
|
| Rate for Payer: Cigna Commercial |
$5,759.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,759.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,759.20
|
| Rate for Payer: Multiplan Commercial |
$6,695.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,119.15
|
| Rate for Payer: United Healthcare Commercial |
$6,839.05
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Facility
|
OP
|
$7,199.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,188.44 |
| Max. Negotiated Rate |
$6,839.05 |
| Rate for Payer: Aetna of VT Commercial |
$6,839.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,449.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,188.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,449.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4,333.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,119.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,831.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,239.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,723.20
|
| Rate for Payer: Cash Price |
$3,599.50
|
| Rate for Payer: Cigna Commercial |
$5,759.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,759.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,759.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,239.55
|
| Rate for Payer: Multiplan Commercial |
$6,695.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,119.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,239.55
|
| Rate for Payer: United Healthcare Commercial |
$6,839.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,239.55
|
| Rate for Payer: United Healthcare VA CCN |
$3,239.55
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Facility
|
IP
|
$1,078.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$797.83 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$797.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$797.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$916.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$905.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$862.40
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: Cigna Commercial |
$862.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$862.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$862.40
|
| Rate for Payer: Multiplan Commercial |
$1,002.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$916.30
|
| Rate for Payer: United Healthcare Commercial |
$1,024.10
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Facility
|
OP
|
$1,078.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$477.45 |
| Max. Negotiated Rate |
$1,024.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$965.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$477.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$965.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$648.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$916.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$873.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$485.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$857.01
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: Cigna Commercial |
$862.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$862.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$862.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$485.10
|
| Rate for Payer: Multiplan Commercial |
$1,002.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$916.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$485.10
|
| Rate for Payer: United Healthcare Commercial |
$1,024.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$485.10
|
| Rate for Payer: United Healthcare VA CCN |
$485.10
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Professional
|
Both
|
$6,122.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
5102193001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$5,754.68 |
| Rate for Payer: Aetna of VT Commercial |
$5,754.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,484.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$353.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,484.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$481.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$395.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$610.51
|
| Rate for Payer: Cash Price |
$3,061.00
|
| Rate for Payer: Cash Price |
$3,061.00
|
| Rate for Payer: Cigna Commercial |
$651.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$472.40
|
| Rate for Payer: Multiplan Commercial |
$5,693.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$487.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare Commercial |
$528.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare VA CCN |
$343.60
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Professional
|
Both
|
$1,078.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$1,013.32 |
| Rate for Payer: Aetna of VT Commercial |
$1,013.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$965.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$353.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$965.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$481.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$395.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$610.51
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: Cigna Commercial |
$651.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$472.40
|
| Rate for Payer: Multiplan Commercial |
$1,002.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$487.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare Commercial |
$528.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare VA CCN |
$343.60
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Professional
|
Both
|
$7,199.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
9602193001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$343.60 |
| Max. Negotiated Rate |
$6,767.06 |
| Rate for Payer: Aetna of VT Commercial |
$6,767.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,449.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$353.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,449.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$481.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$610.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$395.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$610.51
|
| Rate for Payer: Cash Price |
$3,599.50
|
| Rate for Payer: Cash Price |
$3,599.50
|
| Rate for Payer: Cigna Commercial |
$651.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$472.40
|
| Rate for Payer: Multiplan Commercial |
$6,695.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$487.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare Commercial |
$528.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$343.60
|
| Rate for Payer: United Healthcare VA CCN |
$343.60
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Facility
|
IP
|
$6,122.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
5102193001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4,530.89 |
| Max. Negotiated Rate |
$5,815.90 |
| Rate for Payer: Aetna of VT Commercial |
$5,815.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,530.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,530.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,203.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,142.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,897.60
|
| Rate for Payer: Cash Price |
$3,061.00
|
| Rate for Payer: Cigna Commercial |
$4,897.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,897.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,897.60
|
| Rate for Payer: Multiplan Commercial |
$5,693.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,203.70
|
| Rate for Payer: United Healthcare Commercial |
$5,815.90
|
|
|
EXC BACK/FLANK SUB1 < 3 CM
|
Facility
|
OP
|
$6,122.00
|
|
|
Service Code
|
CPT 21930
|
| Hospital Charge Code |
5102193001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,711.43 |
| Max. Negotiated Rate |
$5,815.90 |
| Rate for Payer: Aetna of VT Commercial |
$5,815.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,484.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,711.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,484.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,685.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,203.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,958.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,754.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,866.99
|
| Rate for Payer: Cash Price |
$3,061.00
|
| Rate for Payer: Cigna Commercial |
$4,897.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,897.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,897.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,754.90
|
| Rate for Payer: Multiplan Commercial |
$5,693.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,203.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,754.90
|
| Rate for Payer: United Healthcare Commercial |
$5,815.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,754.90
|
| Rate for Payer: United Healthcare VA CCN |
$2,754.90
|
|
|
EXC BACK LES SC 3 CM/>
|
Facility
|
IP
|
$1,817.00
|
|
|
Service Code
|
CPT 21931
|
| Hospital Charge Code |
9602193101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,344.76 |
| Max. Negotiated Rate |
$1,726.15 |
| Rate for Payer: Aetna of VT Commercial |
$1,726.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,344.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,344.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,544.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,526.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,453.60
|
| Rate for Payer: Cash Price |
$908.50
|
| Rate for Payer: Cigna Commercial |
$1,453.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,453.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,453.60
|
| Rate for Payer: Multiplan Commercial |
$1,689.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,544.45
|
| Rate for Payer: United Healthcare Commercial |
$1,726.15
|
|
|
EXC BACK LES SC 3 CM/>
|
Facility
|
OP
|
$880.00
|
|
|
Service Code
|
CPT 21931
|
| Hospital Charge Code |
9602193102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$389.75 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna of VT Commercial |
$836.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$788.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$389.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$788.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$529.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$748.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$712.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$396.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$699.60
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna Commercial |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$396.00
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$748.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$836.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare VA CCN |
$396.00
|
|
