|
RMVL FB MUSC/TEND SHEATH SMPL
|
Professional
|
Both
|
$2,069.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
5102052001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$140.84 |
| Max. Negotiated Rate |
$1,944.86 |
| Rate for Payer: Aetna of VT Commercial |
$1,944.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,853.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,853.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$197.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$161.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.21
|
| Rate for Payer: Cash Price |
$1,034.50
|
| Rate for Payer: Cash Price |
$1,034.50
|
| Rate for Payer: Cigna Commercial |
$266.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$337.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$337.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$206.68
|
| Rate for Payer: Multiplan Commercial |
$1,924.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.99
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare Commercial |
$216.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare VA CCN |
$140.84
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
9602052002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$140.84 |
| Max. Negotiated Rate |
$404.20 |
| Rate for Payer: Aetna of VT Commercial |
$404.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$385.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$385.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$197.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$161.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.21
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$266.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$337.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$337.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$206.68
|
| Rate for Payer: Multiplan Commercial |
$399.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.99
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare Commercial |
$216.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare VA CCN |
$140.84
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Facility
|
IP
|
$2,069.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
5102052001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,531.27 |
| Max. Negotiated Rate |
$1,965.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,965.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,531.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,531.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,758.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,737.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,655.20
|
| Rate for Payer: Cash Price |
$1,034.50
|
| Rate for Payer: Cigna Commercial |
$1,655.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,655.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,655.20
|
| Rate for Payer: Multiplan Commercial |
$1,924.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,758.65
|
| Rate for Payer: United Healthcare Commercial |
$1,965.55
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Professional
|
Both
|
$2,498.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
9602052001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$140.84 |
| Max. Negotiated Rate |
$2,348.12 |
| Rate for Payer: Aetna of VT Commercial |
$2,348.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,237.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,237.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$197.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$378.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$161.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.21
|
| Rate for Payer: Cash Price |
$1,249.00
|
| Rate for Payer: Cash Price |
$1,249.00
|
| Rate for Payer: Cigna Commercial |
$266.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$337.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$337.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$206.68
|
| Rate for Payer: Multiplan Commercial |
$2,323.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.99
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare Commercial |
$216.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.84
|
| Rate for Payer: United Healthcare VA CCN |
$140.84
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
9602052002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$318.24 |
| Max. Negotiated Rate |
$408.50 |
| Rate for Payer: Aetna of VT Commercial |
$408.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$318.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$318.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$365.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$361.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$344.00
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$344.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$344.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$344.00
|
| Rate for Payer: Multiplan Commercial |
$399.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$365.50
|
| Rate for Payer: United Healthcare Commercial |
$408.50
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Facility
|
IP
|
$2,498.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
9602052001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,848.77 |
| Max. Negotiated Rate |
$2,373.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,373.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,848.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,848.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,123.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,098.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,998.40
|
| Rate for Payer: Cash Price |
$1,249.00
|
| Rate for Payer: Cigna Commercial |
$1,998.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,998.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,998.40
|
| Rate for Payer: Multiplan Commercial |
$2,323.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,123.30
|
| Rate for Payer: United Healthcare Commercial |
$2,373.10
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Facility
|
OP
|
$2,498.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
9602052001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,106.36 |
| Max. Negotiated Rate |
$2,373.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,373.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,237.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,106.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,237.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,503.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,123.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,023.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,124.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,985.91
|
| Rate for Payer: Cash Price |
$1,249.00
|
| Rate for Payer: Cigna Commercial |
$1,998.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,998.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,998.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,124.10
|
| Rate for Payer: Multiplan Commercial |
$2,323.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,123.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,124.10
|
| Rate for Payer: United Healthcare Commercial |
$2,373.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,124.10
|
| Rate for Payer: United Healthcare VA CCN |
$1,124.10
|
|
|
RMVL FB MUSC/TEND SHEATH SMPL
|
Facility
|
OP
|
$2,069.00
|
|
|
Service Code
|
CPT 20520
|
| Hospital Charge Code |
5102052001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$916.36 |
| Max. Negotiated Rate |
$1,965.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,965.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,853.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$916.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,853.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,245.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,758.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,675.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$931.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,644.86
|
| Rate for Payer: Cash Price |
$1,034.50
|
| Rate for Payer: Cigna Commercial |
$1,655.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,655.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,655.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$931.05
|
| Rate for Payer: Multiplan Commercial |
$1,924.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,758.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$931.05
|
| Rate for Payer: United Healthcare Commercial |
$1,965.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$931.05
|
| Rate for Payer: United Healthcare VA CCN |
$931.05
|
|
|
RMVL FB UPPER ARM/ELBW DEEP
|
Facility
|
IP
|
$1,241.00
|
|
|
Service Code
|
CPT 24201
|
| Hospital Charge Code |
9822420101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$918.46 |
| Max. Negotiated Rate |
$1,178.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$918.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$918.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,042.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$992.80
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.80
|
| Rate for Payer: Multiplan Commercial |
$1,154.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.85
|
| Rate for Payer: United Healthcare Commercial |
$1,178.95
|
|
|
RMVL FB UPPER ARM/ELBW DEEP
|
Facility
|
OP
|
$1,241.00
|
|
|
Service Code
|
CPT 24201
|
| Hospital Charge Code |
9822420101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$549.64 |
| Max. Negotiated Rate |
$1,178.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$549.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$747.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,005.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$558.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$986.60
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$558.45
|
| Rate for Payer: Multiplan Commercial |
$1,154.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$558.45
|
| Rate for Payer: United Healthcare Commercial |
$1,178.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$558.45
|
| Rate for Payer: United Healthcare VA CCN |
$558.45
|
|
|
RMVL FB UPPER ARM/ELBW DEEP
|
Professional
|
Both
|
$1,241.00
|
|
|
Service Code
|
CPT 24201
|
| Hospital Charge Code |
9822420101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$384.45 |
| Max. Negotiated Rate |
$1,166.54 |
| Rate for Payer: Aetna of VT Commercial |
$1,166.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$395.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$538.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$980.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$980.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$442.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$980.80
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$726.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$957.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$957.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$584.23
|
| Rate for Payer: Multiplan Commercial |
$1,154.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$384.45
|
| Rate for Payer: United Healthcare Commercial |
$591.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$384.45
|
| Rate for Payer: United Healthcare VA CCN |
$384.45
|
|
|
RMVL FB UPPER ARM/ELBW SUBQ
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
CPT 24200
|
| Hospital Charge Code |
9822420001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$195.32 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna of VT Commercial |
$418.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$195.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$265.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$198.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$350.60
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$352.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$198.45
|
| Rate for Payer: Multiplan Commercial |
$410.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$198.45
|
| Rate for Payer: United Healthcare Commercial |
$418.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$198.45
|
| Rate for Payer: United Healthcare VA CCN |
$198.45
|
|
|
RMVL FB UPPER ARM/ELBW SUBQ
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
CPT 24200
|
| Hospital Charge Code |
9822420001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$136.35 |
| Max. Negotiated Rate |
$414.54 |
| Rate for Payer: Aetna of VT Commercial |
$414.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$140.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$190.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$345.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$345.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$156.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$345.67
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$255.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$345.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$345.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$211.19
|
| Rate for Payer: Multiplan Commercial |
$410.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$193.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$136.35
|
| Rate for Payer: United Healthcare Commercial |
$209.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$136.35
|
| Rate for Payer: United Healthcare VA CCN |
$136.35
|
|
|
RMVL FB UPPER ARM/ELBW SUBQ
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 24200
|
| Hospital Charge Code |
9822420001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$326.38 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna of VT Commercial |
$418.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$326.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$326.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$370.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.80
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$352.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.80
|
| Rate for Payer: Multiplan Commercial |
$410.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.85
|
| Rate for Payer: United Healthcare Commercial |
$418.95
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$544.35 |
| Rate for Payer: Aetna of VT Commercial |
$544.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$513.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$253.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$513.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$344.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$487.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$464.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$257.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$455.54
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$458.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$458.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$458.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$257.85
|
| Rate for Payer: Multiplan Commercial |
$532.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$487.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$257.85
|
| Rate for Payer: United Healthcare Commercial |
$544.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.85
|
| Rate for Payer: United Healthcare VA CCN |
$257.85
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.60 |
| Max. Negotiated Rate |
$359.08 |
| Rate for Payer: Aetna of VT Commercial |
$359.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$342.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$342.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$118.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$97.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$219.89
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$95.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$222.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$222.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$135.03
|
| Rate for Payer: Multiplan Commercial |
$355.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$120.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare Commercial |
$130.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare VA CCN |
$84.60
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
5101197601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.60 |
| Max. Negotiated Rate |
$222.69 |
| Rate for Payer: Aetna of VT Commercial |
$180.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$118.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$97.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$219.89
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$95.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$222.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$222.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$135.03
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$120.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare Commercial |
$130.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare VA CCN |
$84.60
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
5101197601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.04 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna of VT Commercial |
$182.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$85.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$115.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$86.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$152.64
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$153.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$86.40
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$163.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$86.40
|
| Rate for Payer: United Healthcare Commercial |
$182.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.40
|
| Rate for Payer: United Healthcare VA CCN |
$86.40
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Professional
|
Both
|
$573.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.60 |
| Max. Negotiated Rate |
$538.62 |
| Rate for Payer: Aetna of VT Commercial |
$538.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$513.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$513.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$118.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$219.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$97.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$219.89
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$95.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$222.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$222.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$135.03
|
| Rate for Payer: Multiplan Commercial |
$532.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$120.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare Commercial |
$130.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$84.60
|
| Rate for Payer: United Healthcare VA CCN |
$84.60
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
5101197601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna of VT Commercial |
$182.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$142.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$142.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$161.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$153.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$153.60
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$163.20
|
| Rate for Payer: United Healthcare Commercial |
$182.40
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$424.08 |
| Max. Negotiated Rate |
$544.35 |
| Rate for Payer: Aetna of VT Commercial |
$544.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$424.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$424.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$487.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$481.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$458.40
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$458.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$458.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$458.40
|
| Rate for Payer: Multiplan Commercial |
$532.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$487.05
|
| Rate for Payer: United Healthcare Commercial |
$544.35
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$282.72 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna of VT Commercial |
$362.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$282.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$282.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$320.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$305.60
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$305.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$305.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$305.60
|
| Rate for Payer: Multiplan Commercial |
$355.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$324.70
|
| Rate for Payer: United Healthcare Commercial |
$362.90
|
|
|
RMVL IMPLANT CONTRACEPTIVE CAP
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
CPT 11976
|
| Hospital Charge Code |
9601197602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna of VT Commercial |
$362.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$342.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$169.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$342.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$229.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$309.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$171.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$303.69
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$305.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$305.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$305.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$171.90
|
| Rate for Payer: Multiplan Commercial |
$355.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$324.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$171.90
|
| Rate for Payer: United Healthcare Commercial |
$362.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.90
|
| Rate for Payer: United Healthcare VA CCN |
$171.90
|
|
|
RMVL NON-BIOD DRUG DLVR IMPLT
|
Professional
|
Both
|
$176.00
|
|
|
Service Code
|
CPT 11982
|
| Hospital Charge Code |
5101198201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.79 |
| Max. Negotiated Rate |
$230.97 |
| Rate for Payer: Aetna of VT Commercial |
$165.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$68.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$93.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$230.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$230.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$76.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$230.97
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$122.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$170.24
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$170.24
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.09
|
| Rate for Payer: Multiplan Commercial |
$163.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$66.79
|
| Rate for Payer: United Healthcare Commercial |
$102.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66.79
|
| Rate for Payer: United Healthcare VA CCN |
$66.79
|
|
|
RMVL NON-BIOD DRUG DLVR IMPLT
|
Facility
|
IP
|
$516.00
|
|
|
Service Code
|
CPT 11982
|
| Hospital Charge Code |
9601198201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$381.89 |
| Max. Negotiated Rate |
$490.20 |
| Rate for Payer: Aetna of VT Commercial |
$490.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$381.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$381.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$438.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$433.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$412.80
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$412.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$412.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$412.80
|
| Rate for Payer: Multiplan Commercial |
$479.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$438.60
|
| Rate for Payer: United Healthcare Commercial |
$490.20
|
|
