|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$6,801.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
5101930101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$6,392.94 |
| Rate for Payer: Aetna of VT Commercial |
$6,392.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,093.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$624.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,093.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$849.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$697.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$812.12
|
| Rate for Payer: Cash Price |
$3,400.50
|
| Rate for Payer: Cash Price |
$3,400.50
|
| Rate for Payer: Cigna Commercial |
$1,110.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,029.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,029.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$606.45
|
| Rate for Payer: Multiplan Commercial |
$6,324.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$861.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare Commercial |
$932.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare VA CCN |
$606.45
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
IP
|
$8,366.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$6,191.68 |
| Max. Negotiated Rate |
$7,947.70 |
| Rate for Payer: Aetna of VT Commercial |
$7,947.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,191.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,191.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,111.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7,027.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,692.80
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cigna Commercial |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,692.80
|
| Rate for Payer: Multiplan Commercial |
$7,780.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,111.10
|
| Rate for Payer: United Healthcare Commercial |
$7,947.70
|
|
|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$8,366.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$7,864.04 |
| Rate for Payer: Aetna of VT Commercial |
$7,864.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$624.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$849.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$697.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$812.12
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cigna Commercial |
$1,110.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,029.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,029.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$606.45
|
| Rate for Payer: Multiplan Commercial |
$7,780.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$861.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare Commercial |
$932.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare VA CCN |
$606.45
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
IP
|
$1,565.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,158.26 |
| Max. Negotiated Rate |
$1,486.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,158.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,158.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,330.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,314.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,252.00
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,252.00
|
| Rate for Payer: Multiplan Commercial |
$1,455.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,330.25
|
| Rate for Payer: United Healthcare Commercial |
$1,486.75
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
OP
|
$1,565.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$693.14 |
| Max. Negotiated Rate |
$1,486.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,402.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$693.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,402.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$942.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,330.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,267.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$704.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,244.17
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,252.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$704.25
|
| Rate for Payer: Multiplan Commercial |
$1,455.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,330.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$704.25
|
| Rate for Payer: United Healthcare Commercial |
$1,486.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$704.25
|
| Rate for Payer: United Healthcare VA CCN |
$704.25
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
OP
|
$6,801.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
5101930101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,012.16 |
| Max. Negotiated Rate |
$6,460.95 |
| Rate for Payer: Aetna of VT Commercial |
$6,460.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,093.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,012.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,093.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4,094.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,780.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,508.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,060.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,406.80
|
| Rate for Payer: Cash Price |
$3,400.50
|
| Rate for Payer: Cigna Commercial |
$5,440.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,440.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,440.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,060.45
|
| Rate for Payer: Multiplan Commercial |
$6,324.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,780.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,060.45
|
| Rate for Payer: United Healthcare Commercial |
$6,460.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,060.45
|
| Rate for Payer: United Healthcare VA CCN |
$3,060.45
|
|
|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$1,565.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$1,471.10 |
| Rate for Payer: Aetna of VT Commercial |
$1,471.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,402.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$624.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,402.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$849.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$697.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$812.12
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,110.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,029.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,029.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$606.45
|
| Rate for Payer: Multiplan Commercial |
$1,455.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$861.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare Commercial |
$932.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare VA CCN |
$606.45
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
IP
|
$6,801.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
5101930101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5,033.42 |
| Max. Negotiated Rate |
$6,460.95 |
| Rate for Payer: Aetna of VT Commercial |
$6,460.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,033.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,033.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,780.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,712.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,440.80
|
| Rate for Payer: Cash Price |
$3,400.50
|
| Rate for Payer: Cigna Commercial |
$5,440.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,440.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,440.80
|
| Rate for Payer: Multiplan Commercial |
$6,324.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,780.85
|
| Rate for Payer: United Healthcare Commercial |
$6,460.95
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
IP
|
$8,366.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9821930101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$6,191.68 |
| Max. Negotiated Rate |
$7,947.70 |
| Rate for Payer: Aetna of VT Commercial |
$7,947.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,191.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,191.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,111.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7,027.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,692.80
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cigna Commercial |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,692.80
|
| Rate for Payer: Multiplan Commercial |
$7,780.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,111.10
|
| Rate for Payer: United Healthcare Commercial |
$7,947.70
|
|
|
MASTECTOMY PARTIAL
|
Facility
|
OP
|
$8,366.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9601930101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,705.30 |
| Max. Negotiated Rate |
$7,947.70 |
| Rate for Payer: Aetna of VT Commercial |
$7,947.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,705.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5,036.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,111.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,776.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,764.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,650.97
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cigna Commercial |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,692.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,692.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,764.70
|
| Rate for Payer: Multiplan Commercial |
$7,780.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,111.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,764.70
|
| Rate for Payer: United Healthcare Commercial |
$7,947.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,764.70
|
| Rate for Payer: United Healthcare VA CCN |
$3,764.70
|
|
|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$8,366.00
|
|
|
Service Code
|
CPT 19301
|
| Hospital Charge Code |
9821930101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$7,864.04 |
| Rate for Payer: Aetna of VT Commercial |
$7,864.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$624.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,495.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$849.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$812.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$697.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$812.12
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cash Price |
$4,183.00
|
| Rate for Payer: Cigna Commercial |
$1,110.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,029.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,029.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$606.45
|
| Rate for Payer: Multiplan Commercial |
$7,780.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$861.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare Commercial |
$932.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$606.45
|
| Rate for Payer: United Healthcare VA CCN |
$606.45
|
|
|
MAST SIMPLE COMPLETE
|
Professional
|
Both
|
$3,423.00
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
9821930301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$879.66 |
| Max. Negotiated Rate |
$3,217.62 |
| Rate for Payer: Aetna of VT Commercial |
$3,217.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,066.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$906.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,066.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,231.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,421.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,421.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,011.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,421.36
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: Cigna Commercial |
$1,607.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,495.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,495.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$879.66
|
| Rate for Payer: Multiplan Commercial |
$3,183.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,249.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$879.66
|
| Rate for Payer: United Healthcare Commercial |
$1,353.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$879.66
|
| Rate for Payer: United Healthcare VA CCN |
$879.66
|
|
|
MAST SIMPLE COMPLETE
|
Facility
|
OP
|
$3,423.00
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
9821930301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,516.05 |
| Max. Negotiated Rate |
$3,251.85 |
| Rate for Payer: Aetna of VT Commercial |
$3,251.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,066.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,516.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,066.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,060.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,909.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,772.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,540.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,721.28
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: Cigna Commercial |
$2,738.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,738.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,738.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,540.35
|
| Rate for Payer: Multiplan Commercial |
$3,183.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,909.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,540.35
|
| Rate for Payer: United Healthcare Commercial |
$3,251.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,540.35
|
| Rate for Payer: United Healthcare VA CCN |
$1,540.35
|
|
|
MAST SIMPLE COMPLETE
|
Facility
|
IP
|
$3,423.00
|
|
|
Service Code
|
CPT 19303
|
| Hospital Charge Code |
9821930301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$2,533.36 |
| Max. Negotiated Rate |
$3,251.85 |
| Rate for Payer: Aetna of VT Commercial |
$3,251.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,533.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,533.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,909.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,875.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,738.40
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: Cigna Commercial |
$2,738.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,738.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,738.40
|
| Rate for Payer: Multiplan Commercial |
$3,183.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,909.55
|
| Rate for Payer: United Healthcare Commercial |
$3,251.85
|
|
|
MEASURE BLOOD OXYGEN LEVEL
|
Facility
|
IP
|
$265.74
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
4609476201
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$196.67 |
| Max. Negotiated Rate |
$252.45 |
| Rate for Payer: Aetna of VT Commercial |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$196.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$196.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$223.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.59
|
| Rate for Payer: Cash Price |
$132.87
|
| Rate for Payer: Cigna Commercial |
$212.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.59
|
| Rate for Payer: Multiplan Commercial |
$247.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.88
|
| Rate for Payer: United Healthcare Commercial |
$252.45
|
|
|
MEASURE BLOOD OXYGEN LEVEL
|
Facility
|
OP
|
$265.74
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
4609476201
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$117.70 |
| Max. Negotiated Rate |
$252.45 |
| Rate for Payer: Aetna of VT Commercial |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$117.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$238.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$159.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$119.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$211.26
|
| Rate for Payer: Cash Price |
$132.87
|
| Rate for Payer: Cigna Commercial |
$212.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$119.58
|
| Rate for Payer: Multiplan Commercial |
$247.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$119.58
|
| Rate for Payer: United Healthcare Commercial |
$252.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$119.58
|
| Rate for Payer: United Healthcare VA CCN |
$119.58
|
|
|
MECHANICAL TRACTION THERAPY
|
Facility
|
OP
|
$127.18
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
4209701201
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$56.33 |
| Max. Negotiated Rate |
$120.82 |
| Rate for Payer: Aetna of VT Commercial |
$120.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$56.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$76.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$108.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$103.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$57.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$101.11
|
| Rate for Payer: Cash Price |
$63.59
|
| Rate for Payer: Cigna Commercial |
$101.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$101.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$101.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$57.23
|
| Rate for Payer: Multiplan Commercial |
$118.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$57.23
|
| Rate for Payer: United Healthcare Commercial |
$120.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.23
|
| Rate for Payer: United Healthcare VA CCN |
$57.23
|
|
|
MECHANICAL TRACTION THERAPY
|
Facility
|
IP
|
$127.18
|
|
|
Service Code
|
CPT 97012 GP
|
| Hospital Charge Code |
4209701201
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$94.13 |
| Max. Negotiated Rate |
$120.82 |
| Rate for Payer: Aetna of VT Commercial |
$120.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$94.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$94.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$108.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$106.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$101.74
|
| Rate for Payer: Cash Price |
$63.59
|
| Rate for Payer: Cigna Commercial |
$101.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$101.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$101.74
|
| Rate for Payer: Multiplan Commercial |
$118.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.10
|
| Rate for Payer: United Healthcare Commercial |
$120.82
|
|
|
MEDICAL NUTRITION INDIV IN
|
Facility
|
IP
|
$76.52
|
|
|
Service Code
|
CPT 97802
|
| Hospital Charge Code |
9429780201
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$56.63 |
| Max. Negotiated Rate |
$72.69 |
| Rate for Payer: Aetna of VT Commercial |
$72.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$56.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$56.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$64.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$61.22
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cigna Commercial |
$61.22
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.22
|
| Rate for Payer: Multiplan Commercial |
$71.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.04
|
| Rate for Payer: United Healthcare Commercial |
$72.69
|
|
|
MEDICAL NUTRITION INDIV IN
|
Facility
|
OP
|
$76.52
|
|
|
Service Code
|
CPT 97802
|
| Hospital Charge Code |
9429780201
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$72.69 |
| Rate for Payer: Aetna of VT Commercial |
$72.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$33.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$61.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$34.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$60.83
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cigna Commercial |
$61.22
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.43
|
| Rate for Payer: Multiplan Commercial |
$71.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$34.43
|
| Rate for Payer: United Healthcare Commercial |
$72.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.43
|
| Rate for Payer: United Healthcare VA CCN |
$34.43
|
|
|
MEDICAL SERVICES AFTER HRS
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
CPT 99050
|
| Hospital Charge Code |
9829905001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$20.37 |
| Max. Negotiated Rate |
$97.58 |
| Rate for Payer: Aetna of VT Commercial |
$94.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$51.97
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$20.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$97.58
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
| Rate for Payer: United Healthcare Commercial |
$85.00
|
| Rate for Payer: United Healthcare VA CCN |
$40.00
|
|
|
MEDICAL SERVICES AFTER HRS
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 99050
|
| Hospital Charge Code |
9829905001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$74.01 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna of VT Commercial |
$95.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$74.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$74.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$85.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$80.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$80.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$80.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$80.00
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.00
|
| Rate for Payer: United Healthcare Commercial |
$95.00
|
|
|
MEDICAL SERVICES AFTER HRS
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 99050
|
| Hospital Charge Code |
9829905001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna of VT Commercial |
$95.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$44.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$85.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.50
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$80.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$80.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$80.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$93.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$95.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.00
|
| Rate for Payer: United Healthcare VA CCN |
$45.00
|
|
|
MEDICAL TESTIMONY
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 99075
|
| Hospital Charge Code |
9829907501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$76.18 |
| Max. Negotiated Rate |
$163.40 |
| Rate for Payer: Aetna of VT Commercial |
$163.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$76.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$103.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$146.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$136.74
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$137.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$137.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$137.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$77.40
|
| Rate for Payer: Multiplan Commercial |
$159.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$77.40
|
| Rate for Payer: United Healthcare Commercial |
$163.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.40
|
| Rate for Payer: United Healthcare VA CCN |
$77.40
|
|
|
MEDICAL TESTIMONY
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
CPT 99075
|
| Hospital Charge Code |
9829907501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$161.68 |
| Rate for Payer: Aetna of VT Commercial |
$161.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.09
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Multiplan Commercial |
$159.96
|
| Rate for Payer: United Healthcare Commercial |
$146.20
|
| Rate for Payer: United Healthcare VA CCN |
$68.80
|
|
