|
FETAL NON-STRESS TEST
|
Facility
|
IP
|
$846.73
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
4505902501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$626.66 |
| Max. Negotiated Rate |
$804.39 |
| Rate for Payer: Aetna of VT Commercial |
$804.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$626.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$626.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$719.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$711.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$677.38
|
| Rate for Payer: Cash Price |
$423.36
|
| Rate for Payer: Cigna Commercial |
$677.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$677.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$677.38
|
| Rate for Payer: Multiplan Commercial |
$787.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$719.72
|
| Rate for Payer: United Healthcare Commercial |
$804.39
|
|
|
FETAL NON-STRESS TEST
|
Facility
|
IP
|
$473.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
5105902501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$350.07 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Aetna of VT Commercial |
$449.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$350.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$350.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$397.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.40
|
| Rate for Payer: Cash Price |
$236.50
|
| Rate for Payer: Cigna Commercial |
$378.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.40
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.05
|
| Rate for Payer: United Healthcare Commercial |
$449.35
|
|
|
FETAL NON-STRESS TEST
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
9815902502
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$76.97 |
| Max. Negotiated Rate |
$98.80 |
| Rate for Payer: Aetna of VT Commercial |
$98.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$88.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$83.20
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$83.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$83.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$83.20
|
| Rate for Payer: Multiplan Commercial |
$96.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.40
|
| Rate for Payer: United Healthcare Commercial |
$98.80
|
|
|
FETAL NON-STRESS TEST
|
Facility
|
OP
|
$727.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
9605902501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$321.99 |
| Max. Negotiated Rate |
$690.65 |
| Rate for Payer: Aetna of VT Commercial |
$690.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$651.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$321.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$651.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$437.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$617.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$588.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$327.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$577.97
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Cigna Commercial |
$581.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$581.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$581.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$327.15
|
| Rate for Payer: Multiplan Commercial |
$676.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$617.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$327.15
|
| Rate for Payer: United Healthcare Commercial |
$690.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$327.15
|
| Rate for Payer: United Healthcare VA CCN |
$327.15
|
|
|
FETAL NON-STRESS TEST
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
9605902501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$683.38 |
| Rate for Payer: Aetna of VT Commercial |
$683.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$651.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$46.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$651.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$63.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$68.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$68.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$52.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.99
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Cigna Commercial |
$49.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$47.35
|
| Rate for Payer: Multiplan Commercial |
$676.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$64.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.51
|
| Rate for Payer: United Healthcare Commercial |
$70.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.51
|
| Rate for Payer: United Healthcare VA CCN |
$45.51
|
|
|
FIBRIN DEGRADATION QUANT
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
3008537901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna of VT Commercial |
$144.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$121.60
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.60
|
| Rate for Payer: Multiplan Commercial |
$141.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.20
|
| Rate for Payer: United Healthcare Commercial |
$144.40
|
|
|
FIBRIN DEGRADATION QUANT
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
3008537901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$144.40 |
| Rate for Payer: Aetna of VT Commercial |
$144.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$50.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$50.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$91.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$123.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$68.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.84
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.40
|
| Rate for Payer: Multiplan Commercial |
$141.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.40
|
| Rate for Payer: United Healthcare Commercial |
$144.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.18
|
| Rate for Payer: United Healthcare VA CCN |
$68.40
|
|
|
FIBRINOGEN ACTIVITY
|
Facility
|
IP
|
$151.54
|
|
|
Service Code
|
CPT 85384
|
| Hospital Charge Code |
3008538401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.15 |
| Max. Negotiated Rate |
$143.96 |
| Rate for Payer: Aetna of VT Commercial |
$143.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$112.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$112.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$121.23
|
| Rate for Payer: Cash Price |
$75.77
|
| Rate for Payer: Cigna Commercial |
$121.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.23
|
| Rate for Payer: Multiplan Commercial |
$140.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.81
|
| Rate for Payer: United Healthcare Commercial |
$143.96
|
|
|
FIBRINOGEN ACTIVITY
|
Facility
|
OP
|
$151.54
|
|
|
Service Code
|
CPT 85384
|
| Hospital Charge Code |
3008538401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$143.96 |
| Rate for Payer: Aetna of VT Commercial |
$143.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$122.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$68.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.47
|
| Rate for Payer: Cash Price |
$75.77
|
| Rate for Payer: Cash Price |
$75.77
|
| Rate for Payer: Cigna Commercial |
$121.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$121.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$121.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.19
|
| Rate for Payer: Multiplan Commercial |
$140.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.19
|
| Rate for Payer: United Healthcare Commercial |
$143.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.72
|
| Rate for Payer: United Healthcare VA CCN |
$68.19
|
|
|
FIBRINOLYSINS SCREEN I&R
|
Facility
|
IP
|
$80.78
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
3008539001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.79 |
| Max. Negotiated Rate |
$76.74 |
| Rate for Payer: Aetna of VT Commercial |
$76.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$68.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$67.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$64.62
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cigna Commercial |
$64.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.62
|
| Rate for Payer: Multiplan Commercial |
$75.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$68.66
|
| Rate for Payer: United Healthcare Commercial |
$76.74
|
|
|
FIBRINOLYSINS SCREEN I&R
|
Facility
|
OP
|
$80.78
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
3008539001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$76.74 |
| Rate for Payer: Aetna of VT Commercial |
$76.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$48.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$68.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$65.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$36.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$64.22
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cigna Commercial |
$64.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$36.35
|
| Rate for Payer: Multiplan Commercial |
$75.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$68.66
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$36.35
|
| Rate for Payer: United Healthcare Commercial |
$76.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.48
|
| Rate for Payer: United Healthcare VA CCN |
$36.35
|
|
|
FIBRINOLYSINS SCREEN I&R
|
Professional
|
Both
|
$80.78
|
|
|
Service Code
|
CPT 85390
|
| Hospital Charge Code |
3008539001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.26 |
| Max. Negotiated Rate |
$76.28 |
| Rate for Payer: Aetna of VT Commercial |
$75.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$15.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$21.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$40.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$40.27
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cigna Commercial |
$60.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$15.26
|
| Rate for Payer: Multiplan Commercial |
$75.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$15.48
|
| Rate for Payer: United Healthcare Commercial |
$23.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.48
|
| Rate for Payer: United Healthcare VA CCN |
$15.48
|
|
|
FILGRASTIM 300 MCG SYRINGE
|
Facility
|
IP
|
$72.77
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
636Q510101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.86 |
| Max. Negotiated Rate |
$69.13 |
| Rate for Payer: Aetna of VT Commercial |
$69.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$53.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$53.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$61.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$61.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.22
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna Commercial |
$58.22
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.22
|
| Rate for Payer: Multiplan Commercial |
$67.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.85
|
| Rate for Payer: United Healthcare Commercial |
$69.13
|
|
|
FILGRASTIM 300 MCG SYRINGE
|
Facility
|
OP
|
$72.77
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
636Q510101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$69.13 |
| Rate for Payer: Aetna of VT Commercial |
$69.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$32.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$43.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$61.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$32.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$57.85
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna Commercial |
$58.22
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$32.75
|
| Rate for Payer: Multiplan Commercial |
$67.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$32.75
|
| Rate for Payer: United Healthcare Commercial |
$69.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.75
|
| Rate for Payer: United Healthcare VA CCN |
$32.75
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9605717002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$43.36 |
| Max. Negotiated Rate |
$162.05 |
| Rate for Payer: Aetna of VT Commercial |
$150.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$44.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$60.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.05
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$76.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$119.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$119.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.26
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare Commercial |
$66.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare VA CCN |
$43.36
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9605717002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$118.42 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of VT Commercial |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$136.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$128.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$136.00
|
| Rate for Payer: United Healthcare Commercial |
$152.00
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
5105717001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.36 |
| Max. Negotiated Rate |
$171.08 |
| Rate for Payer: Aetna of VT Commercial |
$171.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$163.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$44.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$163.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$60.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.05
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$76.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$119.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$119.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.26
|
| Rate for Payer: Multiplan Commercial |
$169.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare Commercial |
$66.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare VA CCN |
$43.36
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9605717002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$70.86 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of VT Commercial |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$70.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$136.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$127.20
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$136.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$72.00
|
| Rate for Payer: United Healthcare Commercial |
$152.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.00
|
| Rate for Payer: United Healthcare VA CCN |
$72.00
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
5105717001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.61 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna of VT Commercial |
$172.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$163.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$80.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$163.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$109.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$154.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$147.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$81.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$144.69
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$145.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$145.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$145.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$169.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$154.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$81.90
|
| Rate for Payer: United Healthcare Commercial |
$172.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.90
|
| Rate for Payer: United Healthcare VA CCN |
$81.90
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
5105717001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.70 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna of VT Commercial |
$172.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$134.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$134.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$154.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$152.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$145.60
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$145.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$145.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$145.60
|
| Rate for Payer: Multiplan Commercial |
$169.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$154.70
|
| Rate for Payer: United Healthcare Commercial |
$172.90
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9605717001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$151.47 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna of VT Commercial |
$324.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$205.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$277.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$153.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$271.89
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$273.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$153.90
|
| Rate for Payer: Multiplan Commercial |
$318.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$290.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$153.90
|
| Rate for Payer: United Healthcare Commercial |
$324.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$153.90
|
| Rate for Payer: United Healthcare VA CCN |
$153.90
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9825717001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$118.42 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of VT Commercial |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$136.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$128.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$136.00
|
| Rate for Payer: United Healthcare Commercial |
$152.00
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9605717001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$253.11 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna of VT Commercial |
$324.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$253.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$253.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$287.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$273.60
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$273.60
|
| Rate for Payer: Multiplan Commercial |
$318.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$290.70
|
| Rate for Payer: United Healthcare Commercial |
$324.90
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9825717001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$70.86 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of VT Commercial |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$70.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$136.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$127.20
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$136.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$72.00
|
| Rate for Payer: United Healthcare Commercial |
$152.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.00
|
| Rate for Payer: United Healthcare VA CCN |
$72.00
|
|
|
FITTING OF DIAPHRAGM/CAP
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
9825717001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$43.36 |
| Max. Negotiated Rate |
$162.05 |
| Rate for Payer: Aetna of VT Commercial |
$150.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$44.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$60.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.05
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$76.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$119.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$119.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.26
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare Commercial |
$66.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.36
|
| Rate for Payer: United Healthcare VA CCN |
$43.36
|
|
