|
INTMD RPR FACE/MM 2.6-5.0 CM
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9821205201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$270.61 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$270.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$494.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$274.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$485.75
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$274.95
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare VA CCN |
$274.95
|
|
|
INTMD RPR FACE/MM 2.6-5.0 CM
|
Professional
|
Both
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9821205201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$574.34 |
| Rate for Payer: Aetna of VT Commercial |
$574.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$194.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$264.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$216.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.35
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$344.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$484.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$484.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$297.84
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare Commercial |
$290.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare VA CCN |
$188.64
|
|
|
INTMD RPR FACE/MM 2.6-5.0 CM
|
Facility
|
IP
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9821205201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$452.20 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$513.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.80
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
IP
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,153.08 |
| Max. Negotiated Rate |
$1,480.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,480.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,153.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,153.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,324.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,308.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,246.40
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,246.40
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,324.30
|
| Rate for Payer: United Healthcare Commercial |
$1,480.10
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205701
|
|
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 >30.0 CM
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205701
|
|
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 >30.0 CM
|
Professional
|
Both
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9821205701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$392.23 |
| Max. Negotiated Rate |
$1,464.52 |
| Rate for Payer: Aetna of VT Commercial |
$1,464.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$404.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$549.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$451.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$793.64
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$714.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$566.64
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$556.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare Commercial |
$603.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare VA CCN |
$392.23
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
OP
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9821205701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$690.04 |
| Max. Negotiated Rate |
$1,480.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,480.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$690.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$937.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,324.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,261.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$701.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,238.61
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,246.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$701.10
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,324.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$701.10
|
| Rate for Payer: United Healthcare Commercial |
$1,480.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$701.10
|
| Rate for Payer: United Healthcare VA CCN |
$701.10
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
IP
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9821205701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,153.08 |
| Max. Negotiated Rate |
$1,480.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,480.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,153.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,153.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,324.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,308.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,246.40
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,246.40
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,324.30
|
| Rate for Payer: United Healthcare Commercial |
$1,480.10
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
OP
|
$1,556.17
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
4501205701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$689.23 |
| Max. Negotiated Rate |
$1,478.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,478.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,394.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$689.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,394.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$936.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,322.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,260.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$700.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,237.16
|
| Rate for Payer: Cash Price |
$778.08
|
| Rate for Payer: Cigna Commercial |
$1,244.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,244.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,244.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$700.28
|
| Rate for Payer: Multiplan Commercial |
$1,447.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,322.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$700.28
|
| Rate for Payer: United Healthcare Commercial |
$1,478.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$700.28
|
| Rate for Payer: United Healthcare VA CCN |
$700.28
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
IP
|
$1,556.17
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
4501205701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,151.72 |
| Max. Negotiated Rate |
$1,478.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,478.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,151.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,151.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,322.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,307.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,244.94
|
| Rate for Payer: Cash Price |
$778.08
|
| Rate for Payer: Cigna Commercial |
$1,244.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,244.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,244.94
|
| Rate for Payer: Multiplan Commercial |
$1,447.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,322.74
|
| Rate for Payer: United Healthcare Commercial |
$1,478.36
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$932.43 |
| 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 |
$404.00
|
| 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 |
$549.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$451.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$793.64
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$714.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$566.64
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$556.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare Commercial |
$603.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare VA CCN |
$392.23
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Professional
|
Both
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$392.23 |
| Max. Negotiated Rate |
$1,464.52 |
| Rate for Payer: Aetna of VT Commercial |
$1,464.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$404.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$549.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$793.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$451.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$793.64
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$714.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$932.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$932.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$566.64
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$556.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare Commercial |
$603.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$392.23
|
| Rate for Payer: United Healthcare VA CCN |
$392.23
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
OP
|
$1,558.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
9811205702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$690.04 |
| Max. Negotiated Rate |
$1,480.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,480.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$690.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,395.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$937.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,324.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,261.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$701.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,238.61
|
| Rate for Payer: Cash Price |
$779.00
|
| Rate for Payer: Cigna Commercial |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,246.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$701.10
|
| Rate for Payer: Multiplan Commercial |
$1,448.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,324.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$701.10
|
| Rate for Payer: United Healthcare Commercial |
$1,480.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$701.10
|
| Rate for Payer: United Healthcare VA CCN |
$701.10
|
|
|
INTMD RPR FACE/MM 5.1-7.5 CM
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9821205301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$421.86 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$478.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$456.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
|
|
INTMD RPR FACE/MM 5.1-7.5 CM
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9821205301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$252.45 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$343.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$461.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$453.15
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$256.50
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare VA CCN |
$256.50
|
|
|
INTMD RPR FACE/MM 5.1-7.5 CM
|
Professional
|
Both
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9821205301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$203.18 |
| Max. Negotiated Rate |
$556.98 |
| Rate for Payer: Aetna of VT Commercial |
$535.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$284.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$233.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$451.52
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$370.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$556.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$556.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$342.58
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$288.52
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare Commercial |
$312.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare VA CCN |
$203.18
|
|
|
INTMD RPR FACE/MM 7.6-12.5CM
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9821205401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$178.49 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$178.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$242.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$326.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$320.38
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$181.35
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare VA CCN |
$181.35
|
|
|
INTMD RPR FACE/MM 7.6-12.5CM
|
Professional
|
Both
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9821205401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$205.91 |
| Max. Negotiated Rate |
$586.30 |
| Rate for Payer: Aetna of VT Commercial |
$378.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$212.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$288.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$236.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$474.22
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$376.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$586.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$586.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$359.13
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$292.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare Commercial |
$316.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare VA CCN |
$205.91
|
|
|
INTMD RPR FACE/MM 7.6-12.5CM
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9821205401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$338.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$322.40
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
IP
|
$1,424.00
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
9811204602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,053.90 |
| Max. Negotiated Rate |
$1,352.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,352.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,053.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,053.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,210.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,196.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,139.20
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,139.20
|
| Rate for Payer: Multiplan Commercial |
$1,324.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,210.40
|
| Rate for Payer: United Healthcare Commercial |
$1,352.80
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
OP
|
$1,424.00
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
9811204602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$630.69 |
| Max. Negotiated Rate |
$1,352.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,352.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,275.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$630.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,275.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$857.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,210.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,153.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$640.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,132.08
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,139.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$640.80
|
| Rate for Payer: Multiplan Commercial |
$1,324.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,210.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$640.80
|
| Rate for Payer: United Healthcare Commercial |
$1,352.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$640.80
|
| Rate for Payer: United Healthcare VA CCN |
$640.80
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
9811204601
|
|
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 N-HF/GENIT12.6-20
|
Professional
|
Both
|
$972.00
|
|
|
Service Code
|
CPT 12045
|
| Hospital Charge Code |
9811204502
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$255.06 |
| Max. Negotiated Rate |
$913.68 |
| Rate for Payer: Aetna of VT Commercial |
$913.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$870.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$262.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$870.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$357.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$561.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$561.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$293.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$561.03
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cigna Commercial |
$468.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$636.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$636.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$388.36
|
| Rate for Payer: Multiplan Commercial |
$903.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$362.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$255.06
|
| Rate for Payer: United Healthcare Commercial |
$392.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$255.06
|
| Rate for Payer: United Healthcare VA CCN |
$255.06
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
OP
|
$3,825.80
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
4501204601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,694.45 |
| Max. Negotiated Rate |
$3,634.51 |
| Rate for Payer: Aetna of VT Commercial |
$3,634.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,427.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,694.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,427.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,303.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,251.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,098.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,721.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,041.51
|
| Rate for Payer: Cash Price |
$1,912.90
|
| Rate for Payer: Cigna Commercial |
$3,060.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,060.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,060.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,721.61
|
| Rate for Payer: Multiplan Commercial |
$3,557.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,251.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,721.61
|
| Rate for Payer: United Healthcare Commercial |
$3,634.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,721.61
|
| Rate for Payer: United Healthcare VA CCN |
$1,721.61
|
|
