|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Facility
|
IP
|
$4,209.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,115.08 |
| Max. Negotiated Rate |
$3,998.55 |
| Rate for Payer: Aetna of VT Commercial |
$3,998.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,115.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,115.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,577.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,535.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,367.20
|
| Rate for Payer: Cash Price |
$2,104.50
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,367.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,367.20
|
| Rate for Payer: Multiplan Commercial |
$3,914.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,577.65
|
| Rate for Payer: United Healthcare Commercial |
$3,998.55
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Professional
|
Both
|
$4,209.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$361.05 |
| Max. Negotiated Rate |
$3,956.46 |
| Rate for Payer: Aetna of VT Commercial |
$3,956.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,770.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$371.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,770.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$415.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$727.25
|
| Rate for Payer: Cash Price |
$2,104.50
|
| Rate for Payer: Cash Price |
$2,104.50
|
| Rate for Payer: Cigna Commercial |
$406.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$473.79
|
| Rate for Payer: Multiplan Commercial |
$3,914.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare Commercial |
$555.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare VA CCN |
$361.05
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Professional
|
Both
|
$1,286.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$361.05 |
| Max. Negotiated Rate |
$1,208.84 |
| Rate for Payer: Aetna of VT Commercial |
$1,208.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,152.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$371.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,152.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$415.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$727.25
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$406.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$473.79
|
| Rate for Payer: Multiplan Commercial |
$1,195.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare Commercial |
$555.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare VA CCN |
$361.05
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Facility
|
IP
|
$1,286.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$951.77 |
| Max. Negotiated Rate |
$1,221.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,221.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$951.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$951.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,093.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,080.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,028.80
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$1,028.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,028.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,028.80
|
| Rate for Payer: Multiplan Commercial |
$1,195.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,093.10
|
| Rate for Payer: United Healthcare Commercial |
$1,221.70
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
IP
|
$1,142.00
|
|
|
Service Code
|
CPT 28041
|
| Hospital Charge Code |
9822804101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$845.19 |
| Max. Negotiated Rate |
$1,084.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,084.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$845.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$845.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$970.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$959.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$913.60
|
| Rate for Payer: Cash Price |
$571.00
|
| Rate for Payer: Cigna Commercial |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$913.60
|
| Rate for Payer: Multiplan Commercial |
$1,062.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$970.70
|
| Rate for Payer: United Healthcare Commercial |
$1,084.90
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Professional
|
Both
|
$1,142.00
|
|
|
Service Code
|
CPT 28041
|
| Hospital Charge Code |
9822804101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$429.06 |
| Max. Negotiated Rate |
$1,073.48 |
| Rate for Payer: Aetna of VT Commercial |
$1,073.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,023.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$441.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,023.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$600.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$547.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$547.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$493.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$547.05
|
| Rate for Payer: Cash Price |
$571.00
|
| Rate for Payer: Cash Price |
$571.00
|
| Rate for Payer: Cigna Commercial |
$814.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$429.06
|
| Rate for Payer: Multiplan Commercial |
$1,062.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$609.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$429.06
|
| Rate for Payer: United Healthcare Commercial |
$660.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$429.06
|
| Rate for Payer: United Healthcare VA CCN |
$429.06
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
OP
|
$1,142.00
|
|
|
Service Code
|
CPT 28041
|
| Hospital Charge Code |
9822804101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$505.79 |
| Max. Negotiated Rate |
$1,084.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,084.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,023.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$505.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,023.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$687.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$970.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$925.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$513.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$907.89
|
| Rate for Payer: Cash Price |
$571.00
|
| Rate for Payer: Cigna Commercial |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$913.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$513.90
|
| Rate for Payer: Multiplan Commercial |
$1,062.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$970.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$513.90
|
| Rate for Payer: United Healthcare Commercial |
$1,084.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$513.90
|
| Rate for Payer: United Healthcare VA CCN |
$513.90
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
OP
|
$1,055.00
|
|
|
Service Code
|
CPT 28043
|
| Hospital Charge Code |
9822804301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$467.26 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,002.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$945.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$467.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$945.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$635.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$896.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$854.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$474.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$838.73
|
| Rate for Payer: Cash Price |
$527.50
|
| Rate for Payer: Cigna Commercial |
$844.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$844.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$844.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$474.75
|
| Rate for Payer: Multiplan Commercial |
$981.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$896.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$474.75
|
| Rate for Payer: United Healthcare Commercial |
$1,002.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$474.75
|
| Rate for Payer: United Healthcare VA CCN |
$474.75
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Professional
|
Both
|
$1,055.00
|
|
|
Service Code
|
CPT 28043
|
| Hospital Charge Code |
9822804301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$250.26 |
| Max. Negotiated Rate |
$991.70 |
| Rate for Payer: Aetna of VT Commercial |
$991.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$945.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$257.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$945.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$350.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$538.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$538.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$287.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$538.14
|
| Rate for Payer: Cash Price |
$527.50
|
| Rate for Payer: Cash Price |
$527.50
|
| Rate for Payer: Cigna Commercial |
$475.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$586.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$586.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$361.07
|
| Rate for Payer: Multiplan Commercial |
$981.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$355.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.26
|
| Rate for Payer: United Healthcare Commercial |
$384.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.26
|
| Rate for Payer: United Healthcare VA CCN |
$250.26
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
IP
|
$1,055.00
|
|
|
Service Code
|
CPT 28043
|
| Hospital Charge Code |
9822804301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$780.81 |
| Max. Negotiated Rate |
$1,002.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,002.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$780.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$780.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$896.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$886.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$844.00
|
| Rate for Payer: Cash Price |
$527.50
|
| Rate for Payer: Cigna Commercial |
$844.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$844.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$844.00
|
| Rate for Payer: Multiplan Commercial |
$981.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$896.75
|
| Rate for Payer: United Healthcare Commercial |
$1,002.25
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
OP
|
$1,378.00
|
|
|
Service Code
|
CPT 28039
|
| Hospital Charge Code |
9822803901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$610.32 |
| Max. Negotiated Rate |
$1,309.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,309.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,234.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$610.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,234.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$829.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,171.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,116.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$620.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,095.51
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cigna Commercial |
$1,102.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,102.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,102.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$620.10
|
| Rate for Payer: Multiplan Commercial |
$1,281.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,171.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$620.10
|
| Rate for Payer: United Healthcare Commercial |
$1,309.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.10
|
| Rate for Payer: United Healthcare VA CCN |
$620.10
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Professional
|
Both
|
$1,378.00
|
|
|
Service Code
|
CPT 28039
|
| Hospital Charge Code |
9822803901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$320.75 |
| Max. Negotiated Rate |
$1,295.32 |
| Rate for Payer: Aetna of VT Commercial |
$1,295.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,234.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$330.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,234.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$449.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$612.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$612.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$612.87
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cigna Commercial |
$612.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$726.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$726.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$446.02
|
| Rate for Payer: Multiplan Commercial |
$1,281.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$455.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$320.75
|
| Rate for Payer: United Healthcare Commercial |
$493.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$320.75
|
| Rate for Payer: United Healthcare VA CCN |
$320.75
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
IP
|
$1,378.00
|
|
|
Service Code
|
CPT 28039
|
| Hospital Charge Code |
9822803901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,019.86 |
| Max. Negotiated Rate |
$1,309.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,309.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,019.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,019.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,171.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,157.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,102.40
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cigna Commercial |
$1,102.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,102.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,102.40
|
| Rate for Payer: Multiplan Commercial |
$1,281.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,171.30
|
| Rate for Payer: United Healthcare Commercial |
$1,309.10
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
OP
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$516.42 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,107.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$516.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$701.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$991.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$944.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$524.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$926.97
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$524.70
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$991.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$524.70
|
| Rate for Payer: United Healthcare Commercial |
$1,107.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$524.70
|
| Rate for Payer: United Healthcare VA CCN |
$524.70
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$862.96 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,107.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$862.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$862.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$991.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$979.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$932.80
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.80
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$991.10
|
| Rate for Payer: United Healthcare Commercial |
$1,107.70
|
|
|
EXC FOREARM LES SC < 3 CM
|
Professional
|
Both
|
$5,875.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$301.78 |
| Max. Negotiated Rate |
$5,522.50 |
| Rate for Payer: Aetna of VT Commercial |
$5,522.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,263.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$310.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,263.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$422.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$347.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$641.86
|
| Rate for Payer: Cash Price |
$2,937.50
|
| Rate for Payer: Cash Price |
$2,937.50
|
| Rate for Payer: Cigna Commercial |
$570.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$797.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$797.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$486.78
|
| Rate for Payer: Multiplan Commercial |
$5,463.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$428.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare Commercial |
$464.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare VA CCN |
$301.78
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
OP
|
$5,875.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,602.04 |
| Max. Negotiated Rate |
$5,581.25 |
| Rate for Payer: Aetna of VT Commercial |
$5,581.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,263.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,263.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,536.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,993.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,758.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,643.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,670.62
|
| Rate for Payer: Cash Price |
$2,937.50
|
| Rate for Payer: Cigna Commercial |
$4,700.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,700.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,700.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,643.75
|
| Rate for Payer: Multiplan Commercial |
$5,463.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,993.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,643.75
|
| Rate for Payer: United Healthcare Commercial |
$5,581.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,643.75
|
| Rate for Payer: United Healthcare VA CCN |
$2,643.75
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
IP
|
$5,875.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$4,348.09 |
| Max. Negotiated Rate |
$5,581.25 |
| Rate for Payer: Aetna of VT Commercial |
$5,581.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,348.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,348.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,993.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,935.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,700.00
|
| Rate for Payer: Cash Price |
$2,937.50
|
| Rate for Payer: Cigna Commercial |
$4,700.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,700.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,700.00
|
| Rate for Payer: Multiplan Commercial |
$5,463.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,993.75
|
| Rate for Payer: United Healthcare Commercial |
$5,581.25
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
OP
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9822507501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$516.42 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,107.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$516.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$701.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$991.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$944.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$524.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$926.97
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$524.70
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$991.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$524.70
|
| Rate for Payer: United Healthcare Commercial |
$1,107.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$524.70
|
| Rate for Payer: United Healthcare VA CCN |
$524.70
|
|
|
EXC FOREARM LES SC < 3 CM
|
Professional
|
Both
|
$4,709.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
5102507501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.78 |
| Max. Negotiated Rate |
$4,426.46 |
| Rate for Payer: Aetna of VT Commercial |
$4,426.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,218.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$310.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,218.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$422.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$347.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$641.86
|
| Rate for Payer: Cash Price |
$2,354.50
|
| Rate for Payer: Cash Price |
$2,354.50
|
| Rate for Payer: Cigna Commercial |
$570.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$797.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$797.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$486.78
|
| Rate for Payer: Multiplan Commercial |
$4,379.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$428.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare Commercial |
$464.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare VA CCN |
$301.78
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
OP
|
$4,709.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
5102507501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,085.62 |
| Max. Negotiated Rate |
$4,473.55 |
| Rate for Payer: Aetna of VT Commercial |
$4,473.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,218.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,085.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,218.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,834.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,002.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,814.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,119.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,743.66
|
| Rate for Payer: Cash Price |
$2,354.50
|
| Rate for Payer: Cigna Commercial |
$3,767.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,767.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,767.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,119.05
|
| Rate for Payer: Multiplan Commercial |
$4,379.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,002.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,119.05
|
| Rate for Payer: United Healthcare Commercial |
$4,473.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,119.05
|
| Rate for Payer: United Healthcare VA CCN |
$2,119.05
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
IP
|
$4,709.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
5102507501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,485.13 |
| Max. Negotiated Rate |
$4,473.55 |
| Rate for Payer: Aetna of VT Commercial |
$4,473.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,485.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,485.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,002.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,955.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,767.20
|
| Rate for Payer: Cash Price |
$2,354.50
|
| Rate for Payer: Cigna Commercial |
$3,767.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,767.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,767.20
|
| Rate for Payer: Multiplan Commercial |
$4,379.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,002.65
|
| Rate for Payer: United Healthcare Commercial |
$4,473.55
|
|
|
EXC FOREARM LES SC < 3 CM
|
Professional
|
Both
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9822507501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$301.78 |
| Max. Negotiated Rate |
$1,096.04 |
| Rate for Payer: Aetna of VT Commercial |
$1,096.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$310.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$422.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$347.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$641.86
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$570.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$797.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$797.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$486.78
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$428.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare Commercial |
$464.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare VA CCN |
$301.78
|
|
|
EXC FOREARM LES SC < 3 CM
|
Professional
|
Both
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9602507502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$301.78 |
| Max. Negotiated Rate |
$1,096.04 |
| Rate for Payer: Aetna of VT Commercial |
$1,096.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$310.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,044.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$422.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$347.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$641.86
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$570.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$797.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$797.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$486.78
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$428.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare Commercial |
$464.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.78
|
| Rate for Payer: United Healthcare VA CCN |
$301.78
|
|
|
EXC FOREARM LES SC < 3 CM
|
Facility
|
IP
|
$1,166.00
|
|
|
Service Code
|
CPT 25075
|
| Hospital Charge Code |
9822507501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$862.96 |
| Max. Negotiated Rate |
$1,107.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,107.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$862.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$862.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$991.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$979.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$932.80
|
| Rate for Payer: Cash Price |
$583.00
|
| Rate for Payer: Cigna Commercial |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.80
|
| Rate for Payer: Multiplan Commercial |
$1,084.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$991.10
|
| Rate for Payer: United Healthcare Commercial |
$1,107.70
|
|
