|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
IP
|
$817.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$604.66 |
| Max. Negotiated Rate |
$776.15 |
| Rate for Payer: Aetna of VT Commercial |
$776.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$604.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$604.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$694.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$686.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$653.60
|
| Rate for Payer: Cash Price |
$408.50
|
| Rate for Payer: Cigna Commercial |
$653.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$653.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$653.60
|
| Rate for Payer: Multiplan Commercial |
$759.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$694.45
|
| Rate for Payer: United Healthcare Commercial |
$776.15
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
IP
|
$5,527.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
5102101201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4,090.53 |
| Max. Negotiated Rate |
$5,250.65 |
| Rate for Payer: Aetna of VT Commercial |
$5,250.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,090.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,090.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,697.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,642.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,421.60
|
| Rate for Payer: Cash Price |
$2,763.50
|
| Rate for Payer: Cigna Commercial |
$4,421.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,421.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,421.60
|
| Rate for Payer: Multiplan Commercial |
$5,140.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,697.95
|
| Rate for Payer: United Healthcare Commercial |
$5,250.65
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Professional
|
Both
|
$817.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$320.42 |
| Max. Negotiated Rate |
$767.98 |
| Rate for Payer: Aetna of VT Commercial |
$767.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$731.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$330.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$731.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$448.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$368.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$402.82
|
| Rate for Payer: Cash Price |
$408.50
|
| Rate for Payer: Cash Price |
$408.50
|
| Rate for Payer: Cigna Commercial |
$606.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$533.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$533.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$320.42
|
| Rate for Payer: Multiplan Commercial |
$759.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$455.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare Commercial |
$492.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare VA CCN |
$320.42
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
OP
|
$6,344.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,809.76 |
| Max. Negotiated Rate |
$6,026.80 |
| Rate for Payer: Aetna of VT Commercial |
$6,026.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,683.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,809.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,683.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,819.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,392.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,138.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,854.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,043.48
|
| Rate for Payer: Cash Price |
$3,172.00
|
| Rate for Payer: Cigna Commercial |
$5,075.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,075.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,075.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,854.80
|
| Rate for Payer: Multiplan Commercial |
$5,899.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,392.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,854.80
|
| Rate for Payer: United Healthcare Commercial |
$6,026.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,854.80
|
| Rate for Payer: United Healthcare VA CCN |
$2,854.80
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Professional
|
Both
|
$5,527.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
5102101201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$320.42 |
| Max. Negotiated Rate |
$5,195.38 |
| Rate for Payer: Aetna of VT Commercial |
$5,195.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,951.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$330.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,951.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$448.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$368.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$402.82
|
| Rate for Payer: Cash Price |
$2,763.50
|
| Rate for Payer: Cash Price |
$2,763.50
|
| Rate for Payer: Cigna Commercial |
$606.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$533.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$533.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$320.42
|
| Rate for Payer: Multiplan Commercial |
$5,140.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$455.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare Commercial |
$492.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare VA CCN |
$320.42
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
OP
|
$817.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$361.85 |
| Max. Negotiated Rate |
$776.15 |
| Rate for Payer: Aetna of VT Commercial |
$776.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$731.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$361.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$731.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$491.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$694.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$661.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$367.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$649.51
|
| Rate for Payer: Cash Price |
$408.50
|
| Rate for Payer: Cigna Commercial |
$653.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$653.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$653.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$367.65
|
| Rate for Payer: Multiplan Commercial |
$759.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$694.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$367.65
|
| Rate for Payer: United Healthcare Commercial |
$776.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.65
|
| Rate for Payer: United Healthcare VA CCN |
$367.65
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Professional
|
Both
|
$6,344.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$320.42 |
| Max. Negotiated Rate |
$5,963.36 |
| Rate for Payer: Aetna of VT Commercial |
$5,963.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,683.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$330.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,683.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$448.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$402.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$368.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$402.82
|
| Rate for Payer: Cash Price |
$3,172.00
|
| Rate for Payer: Cash Price |
$3,172.00
|
| Rate for Payer: Cigna Commercial |
$606.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$533.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$533.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$320.42
|
| Rate for Payer: Multiplan Commercial |
$5,899.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$455.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare Commercial |
$492.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$320.42
|
| Rate for Payer: United Healthcare VA CCN |
$320.42
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
IP
|
$6,344.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
9602101201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$4,695.19 |
| Max. Negotiated Rate |
$6,026.80 |
| Rate for Payer: Aetna of VT Commercial |
$6,026.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,695.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,695.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,392.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,328.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,075.20
|
| Rate for Payer: Cash Price |
$3,172.00
|
| Rate for Payer: Cigna Commercial |
$5,075.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,075.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,075.20
|
| Rate for Payer: Multiplan Commercial |
$5,899.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,392.40
|
| Rate for Payer: United Healthcare Commercial |
$6,026.80
|
|
|
EXC FACE LES SBQ 2 CM/>
|
Facility
|
OP
|
$5,527.00
|
|
|
Service Code
|
CPT 21012
|
| Hospital Charge Code |
5102101201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,447.91 |
| Max. Negotiated Rate |
$5,250.65 |
| Rate for Payer: Aetna of VT Commercial |
$5,250.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,951.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,447.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,951.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,327.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,697.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,476.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,487.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,393.97
|
| Rate for Payer: Cash Price |
$2,763.50
|
| Rate for Payer: Cigna Commercial |
$4,421.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,421.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,421.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,487.15
|
| Rate for Payer: Multiplan Commercial |
$5,140.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,697.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,487.15
|
| Rate for Payer: United Healthcare Commercial |
$5,250.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,487.15
|
| Rate for Payer: United Healthcare VA CCN |
$2,487.15
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
IP
|
$5,594.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$4,140.12 |
| Max. Negotiated Rate |
$5,314.30 |
| Rate for Payer: Aetna of VT Commercial |
$5,314.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,140.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,140.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,754.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,698.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,475.20
|
| Rate for Payer: Cash Price |
$2,797.00
|
| Rate for Payer: Cigna Commercial |
$4,475.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,475.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,475.20
|
| Rate for Payer: Multiplan Commercial |
$5,202.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,754.90
|
| Rate for Payer: United Healthcare Commercial |
$5,314.30
|
|
|
EXC FACE LES SC <2 CM
|
Professional
|
Both
|
$5,594.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$5,258.36 |
| Rate for Payer: Aetna of VT Commercial |
$5,258.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,011.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$257.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,011.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$350.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$287.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$455.57
|
| Rate for Payer: Cash Price |
$2,797.00
|
| Rate for Payer: Cash Price |
$2,797.00
|
| Rate for Payer: Cigna Commercial |
$471.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$581.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$581.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$355.49
|
| Rate for Payer: Multiplan Commercial |
$5,202.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$355.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare Commercial |
$384.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare VA CCN |
$250.14
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
OP
|
$5,594.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,477.58 |
| Max. Negotiated Rate |
$5,314.30 |
| Rate for Payer: Aetna of VT Commercial |
$5,314.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,011.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,477.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,011.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,367.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,754.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,531.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,517.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,447.23
|
| Rate for Payer: Cash Price |
$2,797.00
|
| Rate for Payer: Cigna Commercial |
$4,475.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,475.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,475.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,517.30
|
| Rate for Payer: Multiplan Commercial |
$5,202.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,754.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,517.30
|
| Rate for Payer: United Healthcare Commercial |
$5,314.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,517.30
|
| Rate for Payer: United Healthcare VA CCN |
$2,517.30
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
IP
|
$4,684.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
5102101101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,466.63 |
| Max. Negotiated Rate |
$4,449.80 |
| Rate for Payer: Aetna of VT Commercial |
$4,449.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,466.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,466.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,981.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,934.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,747.20
|
| Rate for Payer: Cash Price |
$2,342.00
|
| Rate for Payer: Cigna Commercial |
$3,747.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,747.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,747.20
|
| Rate for Payer: Multiplan Commercial |
$4,356.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,981.40
|
| Rate for Payer: United Healthcare Commercial |
$4,449.80
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
OP
|
$4,684.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
5102101101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,074.54 |
| Max. Negotiated Rate |
$4,449.80 |
| Rate for Payer: Aetna of VT Commercial |
$4,449.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,196.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,074.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,196.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,819.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,981.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,794.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,107.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,723.78
|
| Rate for Payer: Cash Price |
$2,342.00
|
| Rate for Payer: Cigna Commercial |
$3,747.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,747.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,747.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,107.80
|
| Rate for Payer: Multiplan Commercial |
$4,356.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,981.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,107.80
|
| Rate for Payer: United Healthcare Commercial |
$4,449.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,107.80
|
| Rate for Payer: United Healthcare VA CCN |
$2,107.80
|
|
|
EXC FACE LES SC <2 CM
|
Professional
|
Both
|
$910.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$855.40 |
| Rate for Payer: Aetna of VT Commercial |
$855.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$815.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$257.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$815.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$350.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$287.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$455.57
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$471.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$581.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$581.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$355.49
|
| Rate for Payer: Multiplan Commercial |
$846.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$355.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare Commercial |
$384.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare VA CCN |
$250.14
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$673.49 |
| Max. Negotiated Rate |
$864.50 |
| Rate for Payer: Aetna of VT Commercial |
$864.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$673.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$673.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$773.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$764.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$728.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$728.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$728.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$728.00
|
| Rate for Payer: Multiplan Commercial |
$846.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$773.50
|
| Rate for Payer: United Healthcare Commercial |
$864.50
|
|
|
EXC FACE LES SC <2 CM
|
Professional
|
Both
|
$4,684.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
5102101101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$4,402.96 |
| Rate for Payer: Aetna of VT Commercial |
$4,402.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,196.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$257.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,196.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$350.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$455.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$287.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$455.57
|
| Rate for Payer: Cash Price |
$2,342.00
|
| Rate for Payer: Cash Price |
$2,342.00
|
| Rate for Payer: Cigna Commercial |
$471.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$581.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$581.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$355.49
|
| Rate for Payer: Multiplan Commercial |
$4,356.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$355.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare Commercial |
$384.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.14
|
| Rate for Payer: United Healthcare VA CCN |
$250.14
|
|
|
EXC FACE LES SC <2 CM
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
CPT 21011
|
| Hospital Charge Code |
9602101102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$403.04 |
| Max. Negotiated Rate |
$864.50 |
| Rate for Payer: Aetna of VT Commercial |
$864.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$815.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$403.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$815.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$547.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$773.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$737.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$409.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$723.45
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$728.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$728.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$728.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$409.50
|
| Rate for Payer: Multiplan Commercial |
$846.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$773.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$409.50
|
| Rate for Payer: United Healthcare Commercial |
$864.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$409.50
|
| Rate for Payer: United Healthcare VA CCN |
$409.50
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
IP
|
$879.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
9821144001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$650.55 |
| Max. Negotiated Rate |
$835.05 |
| Rate for Payer: Aetna of VT Commercial |
$835.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$650.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$650.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$747.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$738.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$703.20
|
| Rate for Payer: Cash Price |
$439.50
|
| Rate for Payer: Cigna Commercial |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$703.20
|
| Rate for Payer: Multiplan Commercial |
$817.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$747.15
|
| Rate for Payer: United Healthcare Commercial |
$835.05
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
OP
|
$879.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
9601144001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$389.31 |
| Max. Negotiated Rate |
$835.05 |
| Rate for Payer: Aetna of VT Commercial |
$835.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$389.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$529.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$747.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$711.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$395.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$698.80
|
| Rate for Payer: Cash Price |
$439.50
|
| Rate for Payer: Cigna Commercial |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$703.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$395.55
|
| Rate for Payer: Multiplan Commercial |
$817.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$747.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$395.55
|
| Rate for Payer: United Healthcare Commercial |
$835.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$395.55
|
| Rate for Payer: United Healthcare VA CCN |
$395.55
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
IP
|
$879.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
9601144001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$650.55 |
| Max. Negotiated Rate |
$835.05 |
| Rate for Payer: Aetna of VT Commercial |
$835.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$650.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$650.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$747.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$738.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$703.20
|
| Rate for Payer: Cash Price |
$439.50
|
| Rate for Payer: Cigna Commercial |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$703.20
|
| Rate for Payer: Multiplan Commercial |
$817.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$747.15
|
| Rate for Payer: United Healthcare Commercial |
$835.05
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
OP
|
$879.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
9821144001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$389.31 |
| Max. Negotiated Rate |
$835.05 |
| Rate for Payer: Aetna of VT Commercial |
$835.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$389.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$787.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$529.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$747.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$711.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$395.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$698.80
|
| Rate for Payer: Cash Price |
$439.50
|
| Rate for Payer: Cigna Commercial |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$703.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$703.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$395.55
|
| Rate for Payer: Multiplan Commercial |
$817.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$747.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$395.55
|
| Rate for Payer: United Healthcare Commercial |
$835.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$395.55
|
| Rate for Payer: United Healthcare VA CCN |
$395.55
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
IP
|
$515.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
5101144001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$381.15 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Aetna of VT Commercial |
$489.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$381.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$381.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$437.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$432.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$412.00
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$412.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$412.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$412.00
|
| Rate for Payer: Multiplan Commercial |
$478.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$437.75
|
| Rate for Payer: United Healthcare Commercial |
$489.25
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
5101144001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$228.09 |
| Max. Negotiated Rate |
$489.25 |
| Rate for Payer: Aetna of VT Commercial |
$489.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$461.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$228.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$461.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$310.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$437.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$417.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$231.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$409.43
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$412.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$412.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$412.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$231.75
|
| Rate for Payer: Multiplan Commercial |
$478.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$437.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$231.75
|
| Rate for Payer: United Healthcare Commercial |
$489.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.75
|
| Rate for Payer: United Healthcare VA CCN |
$231.75
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
9821144001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$103.11 |
| Max. Negotiated Rate |
$342.16 |
| Rate for Payer: Aetna of VT Commercial |
$342.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$326.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$106.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$326.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.46
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cigna Commercial |
$116.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$219.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$219.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$135.55
|
| Rate for Payer: Multiplan Commercial |
$338.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.11
|
| Rate for Payer: United Healthcare Commercial |
$158.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.11
|
| Rate for Payer: United Healthcare VA CCN |
$103.11
|
|
