|
EXC SHOULDER LES SC 3 CM/>
|
Facility
|
OP
|
$5,001.00
|
|
|
Service Code
|
CPT 23071
|
| Hospital Charge Code |
5102307101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,214.94 |
| Max. Negotiated Rate |
$4,750.95 |
| Rate for Payer: Aetna of VT Commercial |
$4,750.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,480.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,214.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,480.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,010.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,250.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,050.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,250.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,975.80
|
| Rate for Payer: Cash Price |
$2,500.50
|
| Rate for Payer: Cigna Commercial |
$4,000.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,000.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,000.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,250.45
|
| Rate for Payer: Multiplan Commercial |
$4,650.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,250.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,250.45
|
| Rate for Payer: United Healthcare Commercial |
$4,750.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,250.45
|
| Rate for Payer: United Healthcare VA CCN |
$2,250.45
|
|
|
EXC SHOULDER LES SC 3 CM/>
|
Facility
|
OP
|
$6,073.00
|
|
|
Service Code
|
CPT 23071
|
| Hospital Charge Code |
9602307101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,689.73 |
| Max. Negotiated Rate |
$5,769.35 |
| Rate for Payer: Aetna of VT Commercial |
$5,769.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,440.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,689.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,440.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,655.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,919.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,732.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,828.03
|
| Rate for Payer: Cash Price |
$3,036.50
|
| Rate for Payer: Cigna Commercial |
$4,858.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,858.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,858.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,732.85
|
| Rate for Payer: Multiplan Commercial |
$5,647.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,162.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,732.85
|
| Rate for Payer: United Healthcare Commercial |
$5,769.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,732.85
|
| Rate for Payer: United Healthcare VA CCN |
$2,732.85
|
|
|
EXC SHOULDER LES SC 3 CM/>
|
Professional
|
Both
|
$6,073.00
|
|
|
Service Code
|
CPT 23071
|
| Hospital Charge Code |
9602307101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$393.99 |
| Max. Negotiated Rate |
$5,708.62 |
| Rate for Payer: Aetna of VT Commercial |
$5,708.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,440.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$405.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,440.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$551.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$497.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$497.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$453.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$497.32
|
| Rate for Payer: Cash Price |
$3,036.50
|
| Rate for Payer: Cash Price |
$3,036.50
|
| Rate for Payer: Cigna Commercial |
$745.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$662.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$662.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$393.99
|
| Rate for Payer: Multiplan Commercial |
$5,647.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$394.00
|
| Rate for Payer: United Healthcare Commercial |
$606.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$394.00
|
| Rate for Payer: United Healthcare VA CCN |
$394.00
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Professional
|
Both
|
$603.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$141.51 |
| Max. Negotiated Rate |
$566.82 |
| Rate for Payer: Aetna of VT Commercial |
$566.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$540.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$540.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$198.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$279.74
|
| Rate for Payer: Cash Price |
$301.50
|
| Rate for Payer: Cash Price |
$301.50
|
| Rate for Payer: Cigna Commercial |
$158.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$354.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$354.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$217.63
|
| Rate for Payer: Multiplan Commercial |
$560.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare Commercial |
$217.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare VA CCN |
$141.51
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
IP
|
$2,052.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,518.69 |
| Max. Negotiated Rate |
$1,949.40 |
| Rate for Payer: Aetna of VT Commercial |
$1,949.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,518.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,518.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,744.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,723.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,641.60
|
| Rate for Payer: Cash Price |
$1,026.00
|
| Rate for Payer: Cigna Commercial |
$1,641.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,641.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,641.60
|
| Rate for Payer: Multiplan Commercial |
$1,908.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,744.20
|
| Rate for Payer: United Healthcare Commercial |
$1,949.40
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$267.07 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Aetna of VT Commercial |
$572.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$540.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$267.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$540.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$363.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$512.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$488.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$271.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$479.38
|
| Rate for Payer: Cash Price |
$301.50
|
| Rate for Payer: Cigna Commercial |
$482.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$482.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$482.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$271.35
|
| Rate for Payer: Multiplan Commercial |
$560.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$271.35
|
| Rate for Payer: United Healthcare Commercial |
$572.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$271.35
|
| Rate for Payer: United Healthcare VA CCN |
$271.35
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Professional
|
Both
|
$1,449.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
5101162101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.51 |
| Max. Negotiated Rate |
$1,362.06 |
| Rate for Payer: Aetna of VT Commercial |
$1,362.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,298.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,298.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$198.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$279.74
|
| Rate for Payer: Cash Price |
$724.50
|
| Rate for Payer: Cash Price |
$724.50
|
| Rate for Payer: Cigna Commercial |
$158.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$354.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$354.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$217.63
|
| Rate for Payer: Multiplan Commercial |
$1,347.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare Commercial |
$217.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare VA CCN |
$141.51
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Professional
|
Both
|
$2,052.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$141.51 |
| Max. Negotiated Rate |
$1,928.88 |
| Rate for Payer: Aetna of VT Commercial |
$1,928.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,838.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,838.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$198.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$279.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$279.74
|
| Rate for Payer: Cash Price |
$1,026.00
|
| Rate for Payer: Cash Price |
$1,026.00
|
| Rate for Payer: Cigna Commercial |
$158.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$354.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$354.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$217.63
|
| Rate for Payer: Multiplan Commercial |
$1,908.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare Commercial |
$217.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.51
|
| Rate for Payer: United Healthcare VA CCN |
$141.51
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
OP
|
$2,052.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$908.83 |
| Max. Negotiated Rate |
$1,949.40 |
| Rate for Payer: Aetna of VT Commercial |
$1,949.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,838.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$908.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,838.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,235.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,744.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,662.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$923.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,631.34
|
| Rate for Payer: Cash Price |
$1,026.00
|
| Rate for Payer: Cigna Commercial |
$1,641.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,641.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,641.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$923.40
|
| Rate for Payer: Multiplan Commercial |
$1,908.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,744.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$923.40
|
| Rate for Payer: United Healthcare Commercial |
$1,949.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$923.40
|
| Rate for Payer: United Healthcare VA CCN |
$923.40
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
OP
|
$1,449.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
5101162101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$641.76 |
| Max. Negotiated Rate |
$1,376.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,376.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,298.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,298.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$872.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,231.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,173.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$652.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,151.95
|
| Rate for Payer: Cash Price |
$724.50
|
| Rate for Payer: Cigna Commercial |
$1,159.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,159.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,159.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$652.05
|
| Rate for Payer: Multiplan Commercial |
$1,347.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,231.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$652.05
|
| Rate for Payer: United Healthcare Commercial |
$1,376.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$652.05
|
| Rate for Payer: United Healthcare VA CCN |
$652.05
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
IP
|
$1,449.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
5101162101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,072.40 |
| Max. Negotiated Rate |
$1,376.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,376.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,072.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,072.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,231.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,217.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,159.20
|
| Rate for Payer: Cash Price |
$724.50
|
| Rate for Payer: Cigna Commercial |
$1,159.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,159.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,159.20
|
| Rate for Payer: Multiplan Commercial |
$1,347.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,231.65
|
| Rate for Payer: United Healthcare Commercial |
$1,376.55
|
|
|
EXC S/N/H/F/G MAL+MRG 0.6-1
|
Facility
|
IP
|
$603.00
|
|
|
Service Code
|
CPT 11621
|
| Hospital Charge Code |
9601162102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$446.28 |
| Max. Negotiated Rate |
$572.85 |
| Rate for Payer: Aetna of VT Commercial |
$572.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$446.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$446.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$512.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$506.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$482.40
|
| Rate for Payer: Cash Price |
$301.50
|
| Rate for Payer: Cigna Commercial |
$482.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$482.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$482.40
|
| Rate for Payer: Multiplan Commercial |
$560.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.55
|
| Rate for Payer: United Healthcare Commercial |
$572.85
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
5101162201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.06 |
| Max. Negotiated Rate |
$390.36 |
| Rate for Payer: Aetna of VT Commercial |
$351.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$184.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.77
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$179.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$240.03
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare Commercial |
$246.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare VA CCN |
$160.06
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$160.06 |
| Max. Negotiated Rate |
$527.34 |
| Rate for Payer: Aetna of VT Commercial |
$527.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$184.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.77
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$179.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$240.03
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare Commercial |
$246.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare VA CCN |
$160.06
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$413.67 |
| Max. Negotiated Rate |
$887.30 |
| Rate for Payer: Aetna of VT Commercial |
$887.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$836.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$413.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$836.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$562.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$793.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$756.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$420.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$742.53
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$747.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$747.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$747.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$420.30
|
| Rate for Payer: Multiplan Commercial |
$868.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$793.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$420.30
|
| Rate for Payer: United Healthcare Commercial |
$887.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$420.30
|
| Rate for Payer: United Healthcare VA CCN |
$420.30
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Professional
|
Both
|
$934.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$160.06 |
| Max. Negotiated Rate |
$877.96 |
| Rate for Payer: Aetna of VT Commercial |
$877.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$836.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$836.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$184.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.77
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$179.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$240.03
|
| Rate for Payer: Multiplan Commercial |
$868.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare Commercial |
$246.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare VA CCN |
$160.06
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
IP
|
$708.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9821162201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$523.99 |
| Max. Negotiated Rate |
$672.60 |
| Rate for Payer: Aetna of VT Commercial |
$672.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$523.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$523.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$601.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$594.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$566.40
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$566.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$566.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$566.40
|
| Rate for Payer: Multiplan Commercial |
$658.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$601.80
|
| Rate for Payer: United Healthcare Commercial |
$672.60
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$248.47 |
| Max. Negotiated Rate |
$532.95 |
| Rate for Payer: Aetna of VT Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$248.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$337.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$476.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$454.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$446.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$448.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.45
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$476.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$252.45
|
| Rate for Payer: United Healthcare Commercial |
$532.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$252.45
|
| Rate for Payer: United Healthcare VA CCN |
$252.45
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$415.20 |
| Max. Negotiated Rate |
$532.95 |
| Rate for Payer: Aetna of VT Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$415.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$415.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$476.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$471.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$448.80
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$448.80
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$476.85
|
| Rate for Payer: United Healthcare Commercial |
$532.95
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
5101162201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.64 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Aetna of VT Commercial |
$355.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$165.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$225.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$302.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$168.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$297.33
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$299.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$168.30
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$168.30
|
| Rate for Payer: United Healthcare Commercial |
$355.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.30
|
| Rate for Payer: United Healthcare VA CCN |
$168.30
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Professional
|
Both
|
$708.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9821162201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$160.06 |
| Max. Negotiated Rate |
$665.52 |
| Rate for Payer: Aetna of VT Commercial |
$665.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$634.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$634.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$184.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.77
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$179.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$390.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$390.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$240.03
|
| Rate for Payer: Multiplan Commercial |
$658.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare Commercial |
$246.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$160.06
|
| Rate for Payer: United Healthcare VA CCN |
$160.06
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
OP
|
$708.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9821162201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$313.57 |
| Max. Negotiated Rate |
$672.60 |
| Rate for Payer: Aetna of VT Commercial |
$672.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$634.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$313.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$634.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$426.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$601.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$573.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$318.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$562.86
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$566.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$566.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$566.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$318.60
|
| Rate for Payer: Multiplan Commercial |
$658.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$601.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$318.60
|
| Rate for Payer: United Healthcare Commercial |
$672.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$318.60
|
| Rate for Payer: United Healthcare VA CCN |
$318.60
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
9601162201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$691.25 |
| Max. Negotiated Rate |
$887.30 |
| Rate for Payer: Aetna of VT Commercial |
$887.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$691.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$691.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$793.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$784.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$747.20
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$747.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$747.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$747.20
|
| Rate for Payer: Multiplan Commercial |
$868.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$793.90
|
| Rate for Payer: United Healthcare Commercial |
$887.30
|
|
|
EXC S/N/H/F/G MAL+MRG 1.1-2
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 11622
|
| Hospital Charge Code |
5101162201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$276.80 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Aetna of VT Commercial |
$355.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$276.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$276.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$314.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$299.20
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$299.20
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.90
|
| Rate for Payer: United Healthcare Commercial |
$355.30
|
|
|
EXC S/N/H/F/G MAL+MRG 2.1-3
|
Facility
|
IP
|
$918.00
|
|
|
Service Code
|
CPT 11623
|
| Hospital Charge Code |
9821162301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$679.41 |
| Max. Negotiated Rate |
$872.10 |
| Rate for Payer: Aetna of VT Commercial |
$872.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$679.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$679.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$780.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$771.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$734.40
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$734.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$734.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$734.40
|
| Rate for Payer: Multiplan Commercial |
$853.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$780.30
|
| Rate for Payer: United Healthcare Commercial |
$872.10
|
|
