|
RECOVERY SERVICES - PHASE 2
|
Facility
|
IP
|
$7.24
|
|
| Hospital Charge Code |
7100000002
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna of VT Commercial |
$6.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5.79
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna Commercial |
$5.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.79
|
| Rate for Payer: Multiplan Commercial |
$6.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.15
|
| Rate for Payer: United Healthcare Commercial |
$6.88
|
|
|
REDUCE TESTIS TORSION
|
Facility
|
OP
|
$2,198.00
|
|
|
Service Code
|
CPT 54600
|
| Hospital Charge Code |
9825460001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$973.49 |
| Max. Negotiated Rate |
$2,088.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,088.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,969.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$973.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,969.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,323.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,868.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,780.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$989.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,747.41
|
| Rate for Payer: Cash Price |
$1,099.00
|
| Rate for Payer: Cigna Commercial |
$1,758.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,758.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,758.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$989.10
|
| Rate for Payer: Multiplan Commercial |
$2,044.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,868.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$989.10
|
| Rate for Payer: United Healthcare Commercial |
$2,088.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$989.10
|
| Rate for Payer: United Healthcare VA CCN |
$989.10
|
|
|
REDUCE TESTIS TORSION
|
Facility
|
IP
|
$2,198.00
|
|
|
Service Code
|
CPT 54600
|
| Hospital Charge Code |
9825460001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,626.74 |
| Max. Negotiated Rate |
$2,088.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,088.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,626.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,626.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,868.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,846.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,758.40
|
| Rate for Payer: Cash Price |
$1,099.00
|
| Rate for Payer: Cigna Commercial |
$1,758.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,758.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,758.40
|
| Rate for Payer: Multiplan Commercial |
$2,044.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,868.30
|
| Rate for Payer: United Healthcare Commercial |
$2,088.10
|
|
|
REDUCE TESTIS TORSION
|
Professional
|
Both
|
$2,198.00
|
|
|
Service Code
|
CPT 54600
|
| Hospital Charge Code |
9825460001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$427.79 |
| Max. Negotiated Rate |
$2,066.12 |
| Rate for Payer: Aetna of VT Commercial |
$2,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,969.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$440.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,969.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$598.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$718.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$718.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$491.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$718.44
|
| Rate for Payer: Cash Price |
$1,099.00
|
| Rate for Payer: Cash Price |
$1,099.00
|
| Rate for Payer: Cigna Commercial |
$744.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$427.80
|
| Rate for Payer: Multiplan Commercial |
$2,044.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$607.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$427.79
|
| Rate for Payer: United Healthcare Commercial |
$658.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$427.79
|
| Rate for Payer: United Healthcare VA CCN |
$427.79
|
|
|
REGADENOSON (LEXISCAN) SYR
|
Facility
|
OP
|
$96.88
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
636J278501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$92.04 |
| Rate for Payer: Aetna of VT Commercial |
$92.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$42.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$58.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$82.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$78.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$77.02
|
| Rate for Payer: Cash Price |
$48.44
|
| Rate for Payer: Cash Price |
$48.44
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$77.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$77.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$43.60
|
| Rate for Payer: Multiplan Commercial |
$90.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$43.60
|
| Rate for Payer: United Healthcare Commercial |
$92.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.60
|
| Rate for Payer: United Healthcare VA CCN |
$43.60
|
|
|
REGADENOSON (LEXISCAN) SYR
|
Facility
|
IP
|
$96.88
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
636J278501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.70 |
| Max. Negotiated Rate |
$92.04 |
| Rate for Payer: Aetna of VT Commercial |
$92.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$71.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$71.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$82.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$81.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$77.50
|
| Rate for Payer: Cash Price |
$48.44
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$77.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$90.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.35
|
| Rate for Payer: United Healthcare Commercial |
$92.04
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9824189901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$82.82 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.66
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$84.15
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare VA CCN |
$84.15
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189902
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$82.82 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.66
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$84.15
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare VA CCN |
$84.15
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189901
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$175.78 |
| Rate for Payer: Aetna of VT Commercial |
$175.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: United Healthcare Commercial |
$158.95
|
| Rate for Payer: United Healthcare VA CCN |
$74.80
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
OP
|
$20,434.57
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
4504189901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$9,050.47 |
| Max. Negotiated Rate |
$19,412.84 |
| Rate for Payer: Aetna of VT Commercial |
$19,412.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18,307.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$9,050.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18,307.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$12,301.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17,369.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16,552.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9,195.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16,245.48
|
| Rate for Payer: Cash Price |
$10,217.28
|
| Rate for Payer: Cigna Commercial |
$16,347.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16,347.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16,347.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$9,195.56
|
| Rate for Payer: Multiplan Commercial |
$19,004.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17,369.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9,195.56
|
| Rate for Payer: United Healthcare Commercial |
$19,412.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,195.56
|
| Rate for Payer: United Healthcare VA CCN |
$9,195.56
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189901
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$138.40 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$149.60
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189902
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$138.40 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$149.60
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9824189901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$175.78 |
| Rate for Payer: Aetna of VT Commercial |
$175.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: United Healthcare Commercial |
$158.95
|
| Rate for Payer: United Healthcare VA CCN |
$74.80
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189901
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$82.82 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.66
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$84.15
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.15
|
| Rate for Payer: United Healthcare VA CCN |
$84.15
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9814189902
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$175.78 |
| Rate for Payer: Aetna of VT Commercial |
$175.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: United Healthcare Commercial |
$158.95
|
| Rate for Payer: United Healthcare VA CCN |
$74.80
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
9824189901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$138.40 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$149.60
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
|
|
REIMPLNT/STBLZ AVULIZED TOOTH
|
Facility
|
IP
|
$20,434.57
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
4504189901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$15,123.63 |
| Max. Negotiated Rate |
$19,412.84 |
| Rate for Payer: Aetna of VT Commercial |
$19,412.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$15,123.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$15,123.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17,369.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17,165.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16,347.66
|
| Rate for Payer: Cash Price |
$10,217.28
|
| Rate for Payer: Cigna Commercial |
$16,347.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16,347.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16,347.66
|
| Rate for Payer: Multiplan Commercial |
$19,004.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17,369.38
|
| Rate for Payer: United Healthcare Commercial |
$19,412.84
|
|
|
REINFORCE HUMERUS
|
Professional
|
Both
|
$2,584.00
|
|
|
Service Code
|
CPT 24498
|
| Hospital Charge Code |
9822449801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$812.47 |
| Max. Negotiated Rate |
$2,428.96 |
| Rate for Payer: Aetna of VT Commercial |
$2,428.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$836.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,137.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,579.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,579.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$934.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,579.82
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$1,545.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,357.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,357.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$812.47
|
| Rate for Payer: Multiplan Commercial |
$2,403.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,153.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$812.48
|
| Rate for Payer: United Healthcare Commercial |
$1,249.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$812.48
|
| Rate for Payer: United Healthcare VA CCN |
$812.48
|
|
|
REINFORCE HUMERUS
|
Facility
|
OP
|
$2,584.00
|
|
|
Service Code
|
CPT 24498
|
| Hospital Charge Code |
9822449801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,144.45 |
| Max. Negotiated Rate |
$2,454.80 |
| Rate for Payer: Aetna of VT Commercial |
$2,454.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,144.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,555.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,196.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,093.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,162.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,054.28
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$2,067.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,067.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,067.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,162.80
|
| Rate for Payer: Multiplan Commercial |
$2,403.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,196.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,162.80
|
| Rate for Payer: United Healthcare Commercial |
$2,454.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,162.80
|
| Rate for Payer: United Healthcare VA CCN |
$1,162.80
|
|
|
REINFORCE HUMERUS
|
Facility
|
IP
|
$2,584.00
|
|
|
Service Code
|
CPT 24498
|
| Hospital Charge Code |
9822449801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,912.42 |
| Max. Negotiated Rate |
$2,454.80 |
| Rate for Payer: Aetna of VT Commercial |
$2,454.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,912.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,912.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,196.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,170.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,067.20
|
| Rate for Payer: Cash Price |
$1,292.00
|
| Rate for Payer: Cigna Commercial |
$2,067.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,067.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,067.20
|
| Rate for Payer: Multiplan Commercial |
$2,403.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,196.40
|
| Rate for Payer: United Healthcare Commercial |
$2,454.80
|
|
|
RELEASE FOOT/TOE NERVE
|
Facility
|
IP
|
$819.00
|
|
|
Service Code
|
CPT 64726
|
| Hospital Charge Code |
9826472601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$606.14 |
| Max. Negotiated Rate |
$778.05 |
| Rate for Payer: Aetna of VT Commercial |
$778.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$606.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$606.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$696.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$687.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$655.20
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cigna Commercial |
$655.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$655.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$655.20
|
| Rate for Payer: Multiplan Commercial |
$761.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$696.15
|
| Rate for Payer: United Healthcare Commercial |
$778.05
|
|
|
RELEASE FOOT/TOE NERVE
|
Facility
|
OP
|
$819.00
|
|
|
Service Code
|
CPT 64726
|
| Hospital Charge Code |
9826472601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$362.74 |
| Max. Negotiated Rate |
$778.05 |
| Rate for Payer: Aetna of VT Commercial |
$778.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$733.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$362.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$733.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$493.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$696.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$663.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$368.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$651.11
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cigna Commercial |
$655.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$655.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$655.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$368.55
|
| Rate for Payer: Multiplan Commercial |
$761.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$696.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$368.55
|
| Rate for Payer: United Healthcare Commercial |
$778.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$368.55
|
| Rate for Payer: United Healthcare VA CCN |
$368.55
|
|
|
RELEASE FOOT/TOE NERVE
|
Professional
|
Both
|
$819.00
|
|
|
Service Code
|
CPT 64726
|
| Hospital Charge Code |
9826472601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$259.81 |
| Max. Negotiated Rate |
$769.86 |
| Rate for Payer: Aetna of VT Commercial |
$769.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$733.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$267.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$733.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$363.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$482.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$482.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$298.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$482.25
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cigna Commercial |
$359.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$424.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$424.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$259.81
|
| Rate for Payer: Multiplan Commercial |
$761.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$368.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$259.81
|
| Rate for Payer: United Healthcare Commercial |
$399.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$259.81
|
| Rate for Payer: United Healthcare VA CCN |
$259.81
|
|
|
RELEASE OF FOOT CONTRACTURE
|
Facility
|
IP
|
$3,010.00
|
|
|
Service Code
|
CPT 28270
|
| Hospital Charge Code |
9602827001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,227.70 |
| Max. Negotiated Rate |
$2,859.50 |
| Rate for Payer: Aetna of VT Commercial |
$2,859.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,227.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,227.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,558.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,528.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,408.00
|
| Rate for Payer: Cash Price |
$1,505.00
|
| Rate for Payer: Cigna Commercial |
$2,408.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,408.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,408.00
|
| Rate for Payer: Multiplan Commercial |
$2,799.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,558.50
|
| Rate for Payer: United Healthcare Commercial |
$2,859.50
|
|
|
RELEASE OF FOOT CONTRACTURE
|
Facility
|
OP
|
$1,351.00
|
|
|
Service Code
|
CPT 28270
|
| Hospital Charge Code |
9822827001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$598.36 |
| Max. Negotiated Rate |
$1,283.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,283.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,210.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$598.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,210.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$813.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,148.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,094.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$607.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,074.05
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cigna Commercial |
$1,080.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,080.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,080.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$607.95
|
| Rate for Payer: Multiplan Commercial |
$1,256.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,148.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$607.95
|
| Rate for Payer: United Healthcare Commercial |
$1,283.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$607.95
|
| Rate for Payer: United Healthcare VA CCN |
$607.95
|
|
