|
LASER FIBER #10494
|
Facility
|
IP
|
$414.00
|
|
| Hospital Charge Code |
2720074501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.40 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.20
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
LASER FIBER #10494
|
Facility
|
OP
|
$414.00
|
|
| Hospital Charge Code |
2720074501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.36 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$249.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.13
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.30
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare VA CCN |
$186.30
|
|
|
LASER FIBER #10495
|
Facility
|
OP
|
$619.50
|
|
| Hospital Charge Code |
2720074471
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$274.38 |
| Max. Negotiated Rate |
$588.52 |
| Rate for Payer: Aetna of VT Commercial |
$588.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$555.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$274.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$555.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$372.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$526.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$501.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$278.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$492.50
|
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: Cigna Commercial |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$495.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$278.77
|
| Rate for Payer: Multiplan Commercial |
$576.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$526.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$278.77
|
| Rate for Payer: United Healthcare Commercial |
$588.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$278.77
|
| Rate for Payer: United Healthcare VA CCN |
$278.77
|
|
|
LASER FIBER #10495
|
Facility
|
IP
|
$619.50
|
|
| Hospital Charge Code |
2720074471
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$458.49 |
| Max. Negotiated Rate |
$588.52 |
| Rate for Payer: Aetna of VT Commercial |
$588.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$458.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$458.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$526.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$520.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$495.60
|
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: Cigna Commercial |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$495.60
|
| Rate for Payer: Multiplan Commercial |
$576.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$526.58
|
| Rate for Payer: United Healthcare Commercial |
$588.52
|
|
|
LASER FIBER #11307
|
Facility
|
IP
|
$414.00
|
|
| Hospital Charge Code |
2720074491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.40 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.20
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
LASER FIBER #11307
|
Facility
|
OP
|
$414.00
|
|
| Hospital Charge Code |
2720074491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.36 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$249.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.13
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.30
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare VA CCN |
$186.30
|
|
|
LASER FIBER #2875
|
Facility
|
OP
|
$413.60
|
|
| Hospital Charge Code |
2720072011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.18 |
| Max. Negotiated Rate |
$392.92 |
| Rate for Payer: Aetna of VT Commercial |
$392.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$248.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$328.81
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cigna Commercial |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$330.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.12
|
| Rate for Payer: Multiplan Commercial |
$384.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.56
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.12
|
| Rate for Payer: United Healthcare Commercial |
$392.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$186.12
|
| Rate for Payer: United Healthcare VA CCN |
$186.12
|
|
|
LASER FIBER #2875
|
Facility
|
IP
|
$413.60
|
|
| Hospital Charge Code |
2720072011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.11 |
| Max. Negotiated Rate |
$392.92 |
| Rate for Payer: Aetna of VT Commercial |
$392.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$330.88
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cigna Commercial |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$330.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$330.88
|
| Rate for Payer: Multiplan Commercial |
$384.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.56
|
| Rate for Payer: United Healthcare Commercial |
$392.92
|
|
|
LASER FIBER #2943/#11308
|
Facility
|
IP
|
$619.50
|
|
| Hospital Charge Code |
2720074431
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$458.49 |
| Max. Negotiated Rate |
$588.52 |
| Rate for Payer: Aetna of VT Commercial |
$588.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$458.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$458.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$526.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$520.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$495.60
|
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: Cigna Commercial |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$495.60
|
| Rate for Payer: Multiplan Commercial |
$576.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$526.58
|
| Rate for Payer: United Healthcare Commercial |
$588.52
|
|
|
LASER FIBER #2943/#11308
|
Facility
|
OP
|
$619.50
|
|
| Hospital Charge Code |
2720074431
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$274.38 |
| Max. Negotiated Rate |
$588.52 |
| Rate for Payer: Aetna of VT Commercial |
$588.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$555.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$274.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$555.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$372.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$526.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$501.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$278.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$492.50
|
| Rate for Payer: Cash Price |
$309.75
|
| Rate for Payer: Cigna Commercial |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$495.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$495.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$278.77
|
| Rate for Payer: Multiplan Commercial |
$576.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$526.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$278.77
|
| Rate for Payer: United Healthcare Commercial |
$588.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$278.77
|
| Rate for Payer: United Healthcare VA CCN |
$278.77
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
5101316001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4,029.84 |
| Max. Negotiated Rate |
$5,172.75 |
| Rate for Payer: Aetna of VT Commercial |
$5,172.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,029.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,029.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,628.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,573.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,356.00
|
| Rate for Payer: Cash Price |
$2,722.50
|
| Rate for Payer: Cigna Commercial |
$4,356.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,356.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,356.00
|
| Rate for Payer: Multiplan Commercial |
$5,063.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,628.25
|
| Rate for Payer: United Healthcare Commercial |
$5,172.75
|
|
|
LATE CLOSURE OF WOUND
|
Professional
|
Both
|
$5,445.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
5101316001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$745.81 |
| Max. Negotiated Rate |
$5,118.30 |
| Rate for Payer: Aetna of VT Commercial |
$5,118.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,878.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$768.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,878.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,044.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$857.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,116.73
|
| Rate for Payer: Cash Price |
$2,722.50
|
| Rate for Payer: Cash Price |
$2,722.50
|
| Rate for Payer: Cigna Commercial |
$1,359.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,240.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,240.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$745.81
|
| Rate for Payer: Multiplan Commercial |
$5,063.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare Commercial |
$1,147.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare VA CCN |
$745.81
|
|
|
LATE CLOSURE OF WOUND
|
Professional
|
Both
|
$7,492.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$745.81 |
| Max. Negotiated Rate |
$7,042.48 |
| Rate for Payer: Aetna of VT Commercial |
$7,042.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,712.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$768.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,712.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,044.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$857.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,116.73
|
| Rate for Payer: Cash Price |
$3,746.00
|
| Rate for Payer: Cash Price |
$3,746.00
|
| Rate for Payer: Cigna Commercial |
$1,359.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,240.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,240.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$745.81
|
| Rate for Payer: Multiplan Commercial |
$6,967.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare Commercial |
$1,147.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare VA CCN |
$745.81
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
5101316001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,411.59 |
| Max. Negotiated Rate |
$5,172.75 |
| Rate for Payer: Aetna of VT Commercial |
$5,172.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,878.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,411.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,878.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,277.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,628.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,410.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,450.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,328.77
|
| Rate for Payer: Cash Price |
$2,722.50
|
| Rate for Payer: Cigna Commercial |
$4,356.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,356.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,356.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,450.25
|
| Rate for Payer: Multiplan Commercial |
$5,063.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,628.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,450.25
|
| Rate for Payer: United Healthcare Commercial |
$5,172.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,450.25
|
| Rate for Payer: United Healthcare VA CCN |
$2,450.25
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
OP
|
$2,048.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$907.06 |
| Max. Negotiated Rate |
$1,945.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,945.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$907.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,232.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,658.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$921.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,628.16
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,638.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$921.60
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$921.60
|
| Rate for Payer: United Healthcare Commercial |
$1,945.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$921.60
|
| Rate for Payer: United Healthcare VA CCN |
$921.60
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
OP
|
$7,492.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,318.21 |
| Max. Negotiated Rate |
$7,117.40 |
| Rate for Payer: Aetna of VT Commercial |
$7,117.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,712.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,318.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,712.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4,510.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,368.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,068.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,371.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,956.14
|
| Rate for Payer: Cash Price |
$3,746.00
|
| Rate for Payer: Cigna Commercial |
$5,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,993.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,371.40
|
| Rate for Payer: Multiplan Commercial |
$6,967.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,368.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,371.40
|
| Rate for Payer: United Healthcare Commercial |
$7,117.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,371.40
|
| Rate for Payer: United Healthcare VA CCN |
$3,371.40
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
IP
|
$7,492.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$5,544.83 |
| Max. Negotiated Rate |
$7,117.40 |
| Rate for Payer: Aetna of VT Commercial |
$7,117.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,544.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,544.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,368.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,293.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,993.60
|
| Rate for Payer: Cash Price |
$3,746.00
|
| Rate for Payer: Cigna Commercial |
$5,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,993.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,993.60
|
| Rate for Payer: Multiplan Commercial |
$6,967.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,368.20
|
| Rate for Payer: United Healthcare Commercial |
$7,117.40
|
|
|
LATE CLOSURE OF WOUND
|
Facility
|
IP
|
$2,048.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,515.72 |
| Max. Negotiated Rate |
$1,945.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,945.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,515.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,515.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,720.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,638.40
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,638.40
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.80
|
| Rate for Payer: United Healthcare Commercial |
$1,945.60
|
|
|
LATE CLOSURE OF WOUND
|
Professional
|
Both
|
$2,048.00
|
|
|
Service Code
|
CPT 13160
|
| Hospital Charge Code |
9601316002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$745.81 |
| Max. Negotiated Rate |
$1,925.12 |
| Rate for Payer: Aetna of VT Commercial |
$1,925.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$768.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,044.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,116.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$857.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,116.73
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$1,359.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,240.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,240.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$745.81
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare Commercial |
$1,147.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$745.81
|
| Rate for Payer: United Healthcare VA CCN |
$745.81
|
|
|
LEUPROLIDE ACETATE 11.25 MG
|
Facility
|
OP
|
$4,593.33
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
636J195001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,593.33 |
| Max. Negotiated Rate |
$4,593.33 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,593.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,593.33
|
|
|
LEUPROLIDE ACETATE 11.25 MG
|
Professional
|
Both
|
$14,771.72
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
636J195001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,666.78 |
| Max. Negotiated Rate |
$13,885.42 |
| Rate for Payer: Aetna of VT Commercial |
$13,885.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,593.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,782.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,593.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,422.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,989.87
|
| Rate for Payer: Cash Price |
$7,385.86
|
| Rate for Payer: Cash Price |
$7,385.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,666.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,666.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,670.30
|
| Rate for Payer: Multiplan Commercial |
$13,737.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,730.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,730.32
|
| Rate for Payer: United Healthcare Commercial |
$2,661.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,730.32
|
| Rate for Payer: United Healthcare VA CCN |
$1,730.32
|
|
|
LEUPROLIDE ACETATE 7.5 MG
|
Facility
|
OP
|
$473.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$473.80 |
| Max. Negotiated Rate |
$473.80 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
|
|
LEUPROLIDE ACETATE 7.5 MG
|
Professional
|
Both
|
$2,332.62
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.29 |
| Max. Negotiated Rate |
$2,192.66 |
| Rate for Payer: Aetna of VT Commercial |
$2,192.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$181.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$247.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$202.92
|
| Rate for Payer: Cash Price |
$1,166.31
|
| Rate for Payer: Cash Price |
$1,166.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$172.29
|
| Rate for Payer: Multiplan Commercial |
$2,169.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare Commercial |
$271.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare VA CCN |
$176.45
|
|
|
LEUPROLIDE INJ, CAMCEVI, 1MG
|
Facility
|
OP
|
$53.97
|
|
|
Service Code
|
HCPCS J1952
|
| Hospital Charge Code |
636J195201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.90 |
| Max. Negotiated Rate |
$144.05 |
| Rate for Payer: Aetna of VT Commercial |
$51.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$144.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$144.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$32.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$43.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$24.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$42.91
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$43.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$43.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$43.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$24.29
|
| Rate for Payer: Multiplan Commercial |
$50.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$24.29
|
| Rate for Payer: United Healthcare Commercial |
$51.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.29
|
| Rate for Payer: United Healthcare VA CCN |
$24.29
|
|
|
LEUPROLIDE INJ, CAMCEVI, 1MG
|
Facility
|
IP
|
$53.97
|
|
|
Service Code
|
HCPCS J1952
|
| Hospital Charge Code |
636J195201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.94 |
| Max. Negotiated Rate |
$51.27 |
| Rate for Payer: Aetna of VT Commercial |
$51.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$45.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$43.18
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$43.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$43.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$43.18
|
| Rate for Payer: Multiplan Commercial |
$50.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.87
|
| Rate for Payer: United Healthcare Commercial |
$51.27
|
|
