|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Professional
|
Both
|
$1,353.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9601205201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$1,271.82 |
| Rate for Payer: Aetna of VT Commercial |
$1,271.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,212.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$194.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,212.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$264.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$216.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.35
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$344.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$484.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$484.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$297.84
|
| Rate for Payer: Multiplan Commercial |
$1,258.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare Commercial |
$290.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare VA CCN |
$188.64
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9811205201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$270.61 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$270.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$494.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$274.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$485.75
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$274.95
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare VA CCN |
$274.95
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Professional
|
Both
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9811205201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$574.34 |
| Rate for Payer: Aetna of VT Commercial |
$574.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$194.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$264.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$391.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$216.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.35
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$344.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$484.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$484.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$297.84
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare Commercial |
$290.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.64
|
| Rate for Payer: United Healthcare VA CCN |
$188.64
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
IP
|
$1,353.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9601205201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,001.36 |
| Max. Negotiated Rate |
$1,285.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,285.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,001.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,001.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,150.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,136.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,082.40
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$1,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,082.40
|
| Rate for Payer: Multiplan Commercial |
$1,258.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,150.05
|
| Rate for Payer: United Healthcare Commercial |
$1,285.35
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
OP
|
$1,353.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9601205201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$599.24 |
| Max. Negotiated Rate |
$1,285.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,285.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,212.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$599.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,212.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$814.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,150.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,095.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$608.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,075.63
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$1,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,082.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$608.85
|
| Rate for Payer: Multiplan Commercial |
$1,258.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,150.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$608.85
|
| Rate for Payer: United Healthcare Commercial |
$1,285.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$608.85
|
| Rate for Payer: United Healthcare VA CCN |
$608.85
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
IP
|
$611.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
9811205202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$452.20 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$513.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.80
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
OP
|
$741.38
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
4501205201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$328.36 |
| Max. Negotiated Rate |
$704.31 |
| Rate for Payer: Aetna of VT Commercial |
$704.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$664.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$328.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$664.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$446.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$630.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$600.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$333.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$589.40
|
| Rate for Payer: Cash Price |
$370.69
|
| Rate for Payer: Cigna Commercial |
$593.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$593.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$593.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$333.62
|
| Rate for Payer: Multiplan Commercial |
$689.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$630.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$333.62
|
| Rate for Payer: United Healthcare Commercial |
$704.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$333.62
|
| Rate for Payer: United Healthcare VA CCN |
$333.62
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
5101205201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$549.15 |
| Max. Negotiated Rate |
$704.90 |
| Rate for Payer: Aetna of VT Commercial |
$704.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$549.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$549.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$630.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$623.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$593.60
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$593.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$593.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$593.60
|
| Rate for Payer: Multiplan Commercial |
$690.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$630.70
|
| Rate for Payer: United Healthcare Commercial |
$704.90
|
|
|
RPR INTMD FACE/MM 2.6-5.0 CM
|
Facility
|
IP
|
$741.38
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
4501205201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$548.70 |
| Max. Negotiated Rate |
$704.31 |
| Rate for Payer: Aetna of VT Commercial |
$704.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$548.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$548.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$630.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$622.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$593.10
|
| Rate for Payer: Cash Price |
$370.69
|
| Rate for Payer: Cigna Commercial |
$593.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$593.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$593.10
|
| Rate for Payer: Multiplan Commercial |
$689.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$630.17
|
| Rate for Payer: United Healthcare Commercial |
$704.31
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
OP
|
$941.50
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
4501205301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$416.99 |
| Max. Negotiated Rate |
$894.42 |
| Rate for Payer: Aetna of VT Commercial |
$894.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$843.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$416.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$843.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$566.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$800.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$762.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$423.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$748.49
|
| Rate for Payer: Cash Price |
$470.75
|
| Rate for Payer: Cigna Commercial |
$753.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$753.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$753.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$423.68
|
| Rate for Payer: Multiplan Commercial |
$875.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$800.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$423.68
|
| Rate for Payer: United Healthcare Commercial |
$894.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$423.68
|
| Rate for Payer: United Healthcare VA CCN |
$423.68
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
IP
|
$941.50
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
4501205301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$696.80 |
| Max. Negotiated Rate |
$894.42 |
| Rate for Payer: Aetna of VT Commercial |
$894.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$696.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$696.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$800.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$790.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$753.20
|
| Rate for Payer: Cash Price |
$470.75
|
| Rate for Payer: Cigna Commercial |
$753.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$753.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$753.20
|
| Rate for Payer: Multiplan Commercial |
$875.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$800.27
|
| Rate for Payer: United Healthcare Commercial |
$894.42
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Professional
|
Both
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$203.18 |
| Max. Negotiated Rate |
$556.98 |
| Rate for Payer: Aetna of VT Commercial |
$535.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$284.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$233.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$451.52
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$370.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$556.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$556.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$342.58
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$288.52
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare Commercial |
$312.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare VA CCN |
$203.18
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Professional
|
Both
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$203.18 |
| Max. Negotiated Rate |
$556.98 |
| Rate for Payer: Aetna of VT Commercial |
$535.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$284.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$451.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$233.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$451.52
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$370.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$556.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$556.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$342.58
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$288.52
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare Commercial |
$312.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$203.18
|
| Rate for Payer: United Healthcare VA CCN |
$203.18
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$252.45 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$343.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$461.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$453.15
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$256.50
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare VA CCN |
$256.50
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$421.86 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$478.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$456.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$421.86 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$478.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$456.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
|
|
RPR INTMD FACE/MM 5.1-7.5 CM
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
9811205302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$252.45 |
| Max. Negotiated Rate |
$541.50 |
| Rate for Payer: Aetna of VT Commercial |
$541.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$510.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$343.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$461.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$453.15
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$456.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$456.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$256.50
|
| Rate for Payer: Multiplan Commercial |
$530.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$484.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$256.50
|
| Rate for Payer: United Healthcare VA CCN |
$256.50
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
IP
|
$328.81
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
4501205401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$243.35 |
| Max. Negotiated Rate |
$312.37 |
| Rate for Payer: Aetna of VT Commercial |
$312.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$243.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$243.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$276.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$263.05
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$263.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$263.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$263.05
|
| Rate for Payer: Multiplan Commercial |
$305.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$279.49
|
| Rate for Payer: United Healthcare Commercial |
$312.37
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$338.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$322.40
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$338.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$322.40
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Professional
|
Both
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$205.91 |
| Max. Negotiated Rate |
$586.30 |
| Rate for Payer: Aetna of VT Commercial |
$378.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$212.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$288.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$236.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$474.22
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$376.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$586.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$586.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$359.13
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$292.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare Commercial |
$316.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare VA CCN |
$205.91
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Professional
|
Both
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$205.91 |
| Max. Negotiated Rate |
$586.30 |
| Rate for Payer: Aetna of VT Commercial |
$378.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$212.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$288.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$474.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$236.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$474.22
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$376.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$586.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$586.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$359.13
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$292.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare Commercial |
$316.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$205.91
|
| Rate for Payer: United Healthcare VA CCN |
$205.91
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
OP
|
$328.81
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
4501205401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$145.63 |
| Max. Negotiated Rate |
$312.37 |
| Rate for Payer: Aetna of VT Commercial |
$312.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$294.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$294.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$197.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$266.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$147.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$261.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$263.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$263.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$263.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$147.96
|
| Rate for Payer: Multiplan Commercial |
$305.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$279.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$147.96
|
| Rate for Payer: United Healthcare Commercial |
$312.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$147.96
|
| Rate for Payer: United Healthcare VA CCN |
$147.96
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$178.49 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$178.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$242.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$326.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$320.38
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$181.35
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare VA CCN |
$181.35
|
|
|
RPR INTMD FACE/MM 7.6-12.5CM
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
9811205401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$178.49 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$178.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$242.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$326.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$320.38
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$181.35
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.35
|
| Rate for Payer: United Healthcare VA CCN |
$181.35
|
|
