|
INTMD RPR N-HF/GENIT 2.5CM/<
|
Facility
|
IP
|
$628.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
5101204101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$464.78 |
| Max. Negotiated Rate |
$596.60 |
| Rate for Payer: Aetna of VT Commercial |
$596.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$464.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$464.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$533.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$527.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$502.40
|
| Rate for Payer: Cash Price |
$314.00
|
| Rate for Payer: Cigna Commercial |
$502.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$502.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$502.40
|
| Rate for Payer: Multiplan Commercial |
$584.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$533.80
|
| Rate for Payer: United Healthcare Commercial |
$596.60
|
|
|
INTMD RPR N-HF/GENIT 2.5CM/<
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
9601204102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$245.37 |
| Max. Negotiated Rate |
$526.30 |
| Rate for Payer: Aetna of VT Commercial |
$526.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$496.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$245.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$496.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$333.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$470.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$448.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$249.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$440.43
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$443.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$249.30
|
| Rate for Payer: Multiplan Commercial |
$515.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$470.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$249.30
|
| Rate for Payer: United Healthcare Commercial |
$526.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$249.30
|
| Rate for Payer: United Healthcare VA CCN |
$249.30
|
|
|
INTMD RPR N-HF/GENIT 2.5CM/<
|
Facility
|
OP
|
$1,181.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
9601204101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$523.06 |
| Max. Negotiated Rate |
$1,121.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,121.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,058.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$523.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,058.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$710.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,003.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$956.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$531.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$938.89
|
| Rate for Payer: Cash Price |
$590.50
|
| Rate for Payer: Cigna Commercial |
$944.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$944.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$944.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$531.45
|
| Rate for Payer: Multiplan Commercial |
$1,098.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,003.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$531.45
|
| Rate for Payer: United Healthcare Commercial |
$1,121.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$531.45
|
| Rate for Payer: United Healthcare VA CCN |
$531.45
|
|
|
INTMD RPR N-HF/GENIT 2.5CM/<
|
Professional
|
Both
|
$1,181.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
9601204101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$137.66 |
| Max. Negotiated Rate |
$1,110.14 |
| Rate for Payer: Aetna of VT Commercial |
$1,110.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,058.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$141.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,058.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$192.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$325.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$325.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$158.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$325.51
|
| Rate for Payer: Cash Price |
$590.50
|
| Rate for Payer: Cash Price |
$590.50
|
| Rate for Payer: Cigna Commercial |
$250.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$404.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$404.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.79
|
| Rate for Payer: Multiplan Commercial |
$1,098.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$137.66
|
| Rate for Payer: United Healthcare Commercial |
$211.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.66
|
| Rate for Payer: United Healthcare VA CCN |
$137.66
|
|
|
INTMD RPR N-HF/GENIT2.6-7.5
|
Facility
|
IP
|
$674.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
9821204201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$498.83 |
| Max. Negotiated Rate |
$640.30 |
| Rate for Payer: Aetna of VT Commercial |
$640.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$498.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$498.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$572.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$566.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$539.20
|
| Rate for Payer: Cash Price |
$337.00
|
| Rate for Payer: Cigna Commercial |
$539.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$539.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$539.20
|
| Rate for Payer: Multiplan Commercial |
$626.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$572.90
|
| Rate for Payer: United Healthcare Commercial |
$640.30
|
|
|
INTMD RPR N-HF/GENIT2.6-7.5
|
Facility
|
OP
|
$674.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
9821204201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$298.51 |
| Max. Negotiated Rate |
$640.30 |
| Rate for Payer: Aetna of VT Commercial |
$640.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$603.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$298.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$603.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$405.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$572.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$545.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$303.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$535.83
|
| Rate for Payer: Cash Price |
$337.00
|
| Rate for Payer: Cigna Commercial |
$539.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$539.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$539.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$303.30
|
| Rate for Payer: Multiplan Commercial |
$626.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$572.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$303.30
|
| Rate for Payer: United Healthcare Commercial |
$640.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$303.30
|
| Rate for Payer: United Healthcare VA CCN |
$303.30
|
|
|
INTMD RPR N-HF/GENIT2.6-7.5
|
Professional
|
Both
|
$674.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
9821204201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$185.39 |
| Max. Negotiated Rate |
$633.56 |
| Rate for Payer: Aetna of VT Commercial |
$633.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$603.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$190.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$603.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$259.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$391.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$213.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.63
|
| Rate for Payer: Cash Price |
$337.00
|
| Rate for Payer: Cash Price |
$337.00
|
| Rate for Payer: Cigna Commercial |
$338.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$476.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$476.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$292.99
|
| Rate for Payer: Multiplan Commercial |
$626.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$263.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$185.39
|
| Rate for Payer: United Healthcare Commercial |
$285.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$185.39
|
| Rate for Payer: United Healthcare VA CCN |
$185.39
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
OP
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$629.80 |
| Max. Negotiated Rate |
$1,350.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,350.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$629.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$856.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,208.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,151.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$639.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,130.49
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,137.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$639.90
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,208.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$639.90
|
| Rate for Payer: United Healthcare Commercial |
$1,350.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$639.90
|
| Rate for Payer: United Healthcare VA CCN |
$639.90
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
IP
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,052.42 |
| Max. Negotiated Rate |
$1,350.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,350.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,052.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,052.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,208.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,194.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,137.60
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,137.60
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,208.70
|
| Rate for Payer: United Healthcare Commercial |
$1,350.90
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Professional
|
Both
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$1,336.68 |
| Rate for Payer: Aetna of VT Commercial |
$1,336.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$334.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$454.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$373.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$708.90
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$594.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$847.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$847.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$511.10
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare Commercial |
$499.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare VA CCN |
$324.80
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
IP
|
$6,229.85
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
4501204701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4,610.71 |
| Max. Negotiated Rate |
$5,918.36 |
| Rate for Payer: Aetna of VT Commercial |
$5,918.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,610.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,610.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,295.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,233.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,983.88
|
| Rate for Payer: Cash Price |
$3,114.93
|
| Rate for Payer: Cigna Commercial |
$4,983.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,983.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,983.88
|
| Rate for Payer: Multiplan Commercial |
$5,793.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,295.37
|
| Rate for Payer: United Healthcare Commercial |
$5,918.36
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
OP
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9821204701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$629.80 |
| Max. Negotiated Rate |
$1,350.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,350.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$629.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$856.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,208.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,151.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$639.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,130.49
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,137.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$639.90
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,208.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$639.90
|
| Rate for Payer: United Healthcare Commercial |
$1,350.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$639.90
|
| Rate for Payer: United Healthcare VA CCN |
$639.90
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$847.57 |
| 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 |
$334.54
|
| 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 |
$454.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$373.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$708.90
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$594.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$847.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$847.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$511.10
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare Commercial |
$499.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare VA CCN |
$324.80
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204701
|
|
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/GENIT >30.0CM
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9811204701
|
|
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 N-HF/GENIT >30.0CM
|
Facility
|
IP
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9821204701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,052.42 |
| Max. Negotiated Rate |
$1,350.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,350.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,052.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,052.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,208.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,194.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,137.60
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,137.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,137.60
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,208.70
|
| Rate for Payer: United Healthcare Commercial |
$1,350.90
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
OP
|
$6,229.85
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
4501204701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,759.20 |
| Max. Negotiated Rate |
$5,918.36 |
| Rate for Payer: Aetna of VT Commercial |
$5,918.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,581.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,759.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,581.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,750.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,295.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,046.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,803.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,952.73
|
| Rate for Payer: Cash Price |
$3,114.93
|
| Rate for Payer: Cigna Commercial |
$4,983.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,983.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,983.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,803.43
|
| Rate for Payer: Multiplan Commercial |
$5,793.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,295.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,803.43
|
| Rate for Payer: United Healthcare Commercial |
$5,918.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,803.43
|
| Rate for Payer: United Healthcare VA CCN |
$2,803.43
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Professional
|
Both
|
$1,422.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
9821204701
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$1,336.68 |
| Rate for Payer: Aetna of VT Commercial |
$1,336.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$334.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,273.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$454.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$708.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$373.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$708.90
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$594.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$847.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$847.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$511.10
|
| Rate for Payer: Multiplan Commercial |
$1,322.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare Commercial |
$499.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.80
|
| Rate for Payer: United Healthcare VA CCN |
$324.80
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Professional
|
Both
|
$788.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
9821204401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$201.81 |
| Max. Negotiated Rate |
$740.72 |
| Rate for Payer: Aetna of VT Commercial |
$740.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$705.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$207.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$705.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$470.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$470.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$470.53
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cigna Commercial |
$368.24
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$588.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$588.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$361.12
|
| Rate for Payer: Multiplan Commercial |
$732.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$286.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$201.81
|
| Rate for Payer: United Healthcare Commercial |
$310.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$201.81
|
| Rate for Payer: United Healthcare VA CCN |
$201.81
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
9821204401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$349.01 |
| Max. Negotiated Rate |
$748.60 |
| Rate for Payer: Aetna of VT Commercial |
$748.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$705.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$349.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$705.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$474.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$669.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$638.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$354.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$626.46
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cigna Commercial |
$630.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$630.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$630.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$354.60
|
| Rate for Payer: Multiplan Commercial |
$732.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$669.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$354.60
|
| Rate for Payer: United Healthcare Commercial |
$748.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$354.60
|
| Rate for Payer: United Healthcare VA CCN |
$354.60
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
9821204401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$583.20 |
| Max. Negotiated Rate |
$748.60 |
| Rate for Payer: Aetna of VT Commercial |
$748.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$583.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$583.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$669.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$661.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$630.40
|
| Rate for Payer: Cash Price |
$394.00
|
| Rate for Payer: Cigna Commercial |
$630.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$630.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$630.40
|
| Rate for Payer: Multiplan Commercial |
$732.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$669.80
|
| Rate for Payer: United Healthcare Commercial |
$748.60
|
|
|
INTMD RPR S/A/T/EXT 12.6-20
|
Professional
|
Both
|
$975.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
9821203501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$225.59 |
| Max. Negotiated Rate |
$916.50 |
| Rate for Payer: Aetna of VT Commercial |
$916.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$873.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$232.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$873.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$315.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$532.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$532.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$259.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$532.35
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$411.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$600.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$600.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$366.28
|
| Rate for Payer: Multiplan Commercial |
$906.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$320.34
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$225.59
|
| Rate for Payer: United Healthcare Commercial |
$347.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.59
|
| Rate for Payer: United Healthcare VA CCN |
$225.59
|
|
|
INTMD RPR S/A/T/EXT 12.6-20
|
Facility
|
OP
|
$975.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
9821203501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$431.83 |
| Max. Negotiated Rate |
$926.25 |
| Rate for Payer: Aetna of VT Commercial |
$926.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$873.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$431.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$873.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$586.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$828.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$789.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$438.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$775.12
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$780.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$438.75
|
| Rate for Payer: Multiplan Commercial |
$906.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$828.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$438.75
|
| Rate for Payer: United Healthcare Commercial |
$926.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$438.75
|
| Rate for Payer: United Healthcare VA CCN |
$438.75
|
|
|
INTMD RPR S/A/T/EXT 12.6-20
|
Facility
|
IP
|
$975.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
9821203501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$721.60 |
| Max. Negotiated Rate |
$926.25 |
| Rate for Payer: Aetna of VT Commercial |
$926.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$721.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$721.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$828.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$819.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$780.00
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$780.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.00
|
| Rate for Payer: Multiplan Commercial |
$906.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$828.75
|
| Rate for Payer: United Healthcare Commercial |
$926.25
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$1,118.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,118.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$269.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$366.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$301.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$596.31
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$477.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$407.55
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$372.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare Commercial |
$403.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare VA CCN |
$262.05
|
|
