|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
IP
|
$121.50
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
4501600001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$89.92 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna of VT Commercial |
$115.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$103.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$97.20
|
| Rate for Payer: Cash Price |
$60.75
|
| Rate for Payer: Cigna Commercial |
$97.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$97.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$97.20
|
| Rate for Payer: Multiplan Commercial |
$113.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$103.28
|
| Rate for Payer: United Healthcare Commercial |
$115.42
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$146.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$139.20
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$41.90 |
| Max. Negotiated Rate |
$163.56 |
| Rate for Payer: Aetna of VT Commercial |
$163.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$58.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$110.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$110.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$48.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$110.43
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$47.24
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$75.63
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$41.90
|
| Rate for Payer: United Healthcare Commercial |
$64.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.90
|
| Rate for Payer: United Healthcare VA CCN |
$41.90
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$146.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$139.20
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
OP
|
$121.50
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
4501600001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$53.81 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna of VT Commercial |
$115.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$108.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$108.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$73.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$103.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$98.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$54.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.59
|
| Rate for Payer: Cash Price |
$60.75
|
| Rate for Payer: Cigna Commercial |
$97.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$97.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$97.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$54.67
|
| Rate for Payer: Multiplan Commercial |
$113.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$103.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$54.67
|
| Rate for Payer: United Healthcare Commercial |
$115.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.67
|
| Rate for Payer: United Healthcare VA CCN |
$54.67
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$41.90 |
| Max. Negotiated Rate |
$163.56 |
| Rate for Payer: Aetna of VT Commercial |
$163.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$58.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$110.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$110.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$48.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$110.43
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$47.24
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$75.63
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$41.90
|
| Rate for Payer: United Healthcare Commercial |
$64.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.90
|
| Rate for Payer: United Healthcare VA CCN |
$41.90
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$77.06 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$77.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$104.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$138.33
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare VA CCN |
$78.30
|
|
|
INTL TX 1ST DEGREE BURN LOCAL
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
9811600002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$77.06 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$77.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$104.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$138.33
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare VA CCN |
$78.30
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Professional
|
Both
|
$1,211.00
|
|
|
Service Code
|
CPT 12055
|
| Hospital Charge Code |
9821205501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$280.39 |
| Max. Negotiated Rate |
$1,138.34 |
| Rate for Payer: Aetna of VT Commercial |
$1,138.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,084.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$288.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,084.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$392.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$614.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$614.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$322.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$614.60
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: Cigna Commercial |
$514.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$771.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$771.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$470.54
|
| Rate for Payer: Multiplan Commercial |
$1,126.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$398.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$280.39
|
| Rate for Payer: United Healthcare Commercial |
$431.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$280.39
|
| Rate for Payer: United Healthcare VA CCN |
$280.39
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
IP
|
$1,211.00
|
|
|
Service Code
|
CPT 12055
|
| Hospital Charge Code |
9821205501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$896.26 |
| Max. Negotiated Rate |
$1,150.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,150.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$896.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$896.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,017.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$968.80
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: Cigna Commercial |
$968.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$968.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$968.80
|
| Rate for Payer: Multiplan Commercial |
$1,126.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,029.35
|
| Rate for Payer: United Healthcare Commercial |
$1,150.45
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
OP
|
$1,211.00
|
|
|
Service Code
|
CPT 12055
|
| Hospital Charge Code |
9821205501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$536.35 |
| Max. Negotiated Rate |
$1,150.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,150.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,084.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$536.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,084.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$729.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$980.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$544.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$962.75
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: Cigna Commercial |
$968.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$968.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$968.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$544.95
|
| Rate for Payer: Multiplan Commercial |
$1,126.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,029.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$544.95
|
| Rate for Payer: United Healthcare Commercial |
$1,150.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$544.95
|
| Rate for Payer: United Healthcare VA CCN |
$544.95
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205601
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205601
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Professional
|
Both
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9821205601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$360.02 |
| Max. Negotiated Rate |
$1,382.74 |
| Rate for Payer: Aetna of VT Commercial |
$1,382.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$370.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$504.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$414.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$772.35
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$655.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$893.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$893.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$544.39
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$511.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare Commercial |
$553.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare VA CCN |
$360.02
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
IP
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,088.69 |
| Max. Negotiated Rate |
$1,397.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,397.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,088.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,088.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,250.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,235.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,176.80
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,176.80
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,250.35
|
| Rate for Payer: United Healthcare Commercial |
$1,397.45
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205601
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$893.86 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$370.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$504.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$414.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$772.35
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$655.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$893.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$893.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$544.39
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$511.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare Commercial |
$553.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare VA CCN |
$360.02
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Professional
|
Both
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$360.02 |
| Max. Negotiated Rate |
$1,382.74 |
| Rate for Payer: Aetna of VT Commercial |
$1,382.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$370.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$504.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$772.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$414.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$772.35
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$655.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$893.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$893.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$544.39
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$511.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare Commercial |
$553.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$360.02
|
| Rate for Payer: United Healthcare VA CCN |
$360.02
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
IP
|
$3,034.79
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
4501205601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,246.05 |
| Max. Negotiated Rate |
$2,883.05 |
| Rate for Payer: Aetna of VT Commercial |
$2,883.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,246.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,579.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,549.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,427.83
|
| Rate for Payer: Cash Price |
$1,517.39
|
| Rate for Payer: Cigna Commercial |
$2,427.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,427.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,427.83
|
| Rate for Payer: Multiplan Commercial |
$2,822.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,579.57
|
| Rate for Payer: United Healthcare Commercial |
$2,883.05
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
OP
|
$3,034.79
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
4501205601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,344.11 |
| Max. Negotiated Rate |
$2,883.05 |
| Rate for Payer: Aetna of VT Commercial |
$2,883.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,718.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,344.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,718.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,826.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,579.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,458.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,365.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,412.66
|
| Rate for Payer: Cash Price |
$1,517.39
|
| Rate for Payer: Cigna Commercial |
$2,427.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,427.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,427.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,365.66
|
| Rate for Payer: Multiplan Commercial |
$2,822.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,579.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,365.66
|
| Rate for Payer: United Healthcare Commercial |
$2,883.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,365.66
|
| Rate for Payer: United Healthcare VA CCN |
$1,365.66
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
OP
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9821205601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$651.51 |
| Max. Negotiated Rate |
$1,397.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,397.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$651.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$885.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,250.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,191.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$661.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,169.44
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,176.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$661.95
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,250.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$661.95
|
| Rate for Payer: United Healthcare Commercial |
$1,397.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$661.95
|
| Rate for Payer: United Healthcare VA CCN |
$661.95
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
IP
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9821205601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,088.69 |
| Max. Negotiated Rate |
$1,397.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,397.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,088.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,088.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,250.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,235.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,176.80
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,176.80
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,250.35
|
| Rate for Payer: United Healthcare Commercial |
$1,397.45
|
|
|
INTMD RPR FACE/MM 20.1-30.0
|
Facility
|
OP
|
$1,471.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
9811205602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$651.51 |
| Max. Negotiated Rate |
$1,397.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,397.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$651.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,317.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$885.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,250.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,191.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$661.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,169.44
|
| Rate for Payer: Cash Price |
$735.50
|
| Rate for Payer: Cigna Commercial |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,176.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,176.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$661.95
|
| Rate for Payer: Multiplan Commercial |
$1,368.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,250.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$661.95
|
| Rate for Payer: United Healthcare Commercial |
$1,397.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$661.95
|
| Rate for Payer: United Healthcare VA CCN |
$661.95
|
|
|
INTMD RPR FACE/MM 2.5 CM/<
|
Facility
|
OP
|
$676.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
9821205101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$299.40 |
| Max. Negotiated Rate |
$642.20 |
| Rate for Payer: Aetna of VT Commercial |
$642.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$605.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$299.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$605.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$406.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$574.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$547.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$304.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$537.42
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$540.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$540.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$540.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$304.20
|
| Rate for Payer: Multiplan Commercial |
$628.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$574.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$304.20
|
| Rate for Payer: United Healthcare Commercial |
$642.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$304.20
|
| Rate for Payer: United Healthcare VA CCN |
$304.20
|
|
|
INTMD RPR FACE/MM 2.5 CM/<
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
9821205101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$159.88 |
| Max. Negotiated Rate |
$635.44 |
| Rate for Payer: Aetna of VT Commercial |
$635.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$605.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$605.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$223.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$368.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$368.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$183.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$368.01
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$292.61
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$433.55
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$433.55
|
| Rate for Payer: Martins Point Health Care Commercial |
$266.84
|
| Rate for Payer: Multiplan Commercial |
$628.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$159.88
|
| Rate for Payer: United Healthcare Commercial |
$245.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$159.88
|
| Rate for Payer: United Healthcare VA CCN |
$159.88
|
|
|
INTMD RPR FACE/MM 2.5 CM/<
|
Facility
|
IP
|
$676.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
9821205101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$500.31 |
| Max. Negotiated Rate |
$642.20 |
| Rate for Payer: Aetna of VT Commercial |
$642.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$500.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$500.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$574.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$567.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$540.80
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$540.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$540.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$540.80
|
| Rate for Payer: Multiplan Commercial |
$628.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$574.60
|
| Rate for Payer: United Healthcare Commercial |
$642.20
|
|
