|
SIGMOIDOSCOPY AND BIOPSY
|
Professional
|
Both
|
$1,303.00
|
|
|
Service Code
|
CPT 45331
|
| Hospital Charge Code |
5104533101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$1,224.82 |
| Rate for Payer: Aetna of VT Commercial |
$1,224.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,167.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,167.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$365.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$365.77
|
| Rate for Payer: Cash Price |
$651.50
|
| Rate for Payer: Cash Price |
$651.50
|
| Rate for Payer: Cigna Commercial |
$123.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$432.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$432.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$267.93
|
| Rate for Payer: Multiplan Commercial |
$1,211.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$95.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.50
|
| Rate for Payer: United Healthcare Commercial |
$103.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.50
|
| Rate for Payer: United Healthcare VA CCN |
$67.50
|
|
|
SIGMOIDOSCOPY AND BIOPSY
|
Facility
|
OP
|
$1,719.00
|
|
|
Service Code
|
CPT 45331
|
| Hospital Charge Code |
9604533101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$761.35 |
| Max. Negotiated Rate |
$1,633.05 |
| Rate for Payer: Aetna of VT Commercial |
$1,633.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,540.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$761.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,540.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,034.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,461.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,392.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$773.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,366.61
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cigna Commercial |
$1,375.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,375.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,375.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$773.55
|
| Rate for Payer: Multiplan Commercial |
$1,598.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,461.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$773.55
|
| Rate for Payer: United Healthcare Commercial |
$1,633.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$773.55
|
| Rate for Payer: United Healthcare VA CCN |
$773.55
|
|
|
SIGMOIDOSCOPY AND BIOPSY
|
Professional
|
Both
|
$1,719.00
|
|
|
Service Code
|
CPT 45331
|
| Hospital Charge Code |
9604533101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$1,615.86 |
| Rate for Payer: Aetna of VT Commercial |
$1,615.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,540.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,540.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$365.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$365.77
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cash Price |
$859.50
|
| Rate for Payer: Cigna Commercial |
$123.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$432.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$432.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$267.93
|
| Rate for Payer: Multiplan Commercial |
$1,598.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$95.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.50
|
| Rate for Payer: United Healthcare Commercial |
$103.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.50
|
| Rate for Payer: United Healthcare VA CCN |
$67.50
|
|
|
SILVADENE 1% CREAM
|
Professional
|
Both
|
$18.50
|
|
|
Service Code
|
NDC 4359821025
|
| Hospital Charge Code |
2500000276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$17.39 |
| Rate for Payer: Aetna of VT Commercial |
$17.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.57
|
| Rate for Payer: Cash Price |
$9.25
|
| Rate for Payer: Multiplan Commercial |
$17.20
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare VA CCN |
$7.40
|
|
|
SILVADENE 1% CREAM
|
Professional
|
Both
|
$18.50
|
|
| Hospital Charge Code |
2500000276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$17.39 |
| Rate for Payer: Aetna of VT Commercial |
$17.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.57
|
| Rate for Payer: Cash Price |
$9.25
|
| Rate for Payer: Multiplan Commercial |
$17.20
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare VA CCN |
$7.40
|
|
|
SILVER NITRATE APPLICATOR
|
Professional
|
Both
|
$0.03
|
|
| Hospital Charge Code |
2500000310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
SILVER NITRATE APPLICATOR
|
Professional
|
Both
|
$0.03
|
|
|
Service Code
|
NDC 1287000011
|
| Hospital Charge Code |
2500000310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
SINCALIDE 5 MCG VIAL
|
Facility
|
IP
|
$546.41
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
636J280501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$404.40 |
| Max. Negotiated Rate |
$519.09 |
| Rate for Payer: Aetna of VT Commercial |
$519.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$404.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$404.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$464.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$458.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$437.13
|
| Rate for Payer: Cash Price |
$273.20
|
| Rate for Payer: Cigna Commercial |
$437.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$437.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$437.13
|
| Rate for Payer: Multiplan Commercial |
$508.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$464.45
|
| Rate for Payer: United Healthcare Commercial |
$519.09
|
|
|
SINCALIDE 5 MCG VIAL
|
Facility
|
OP
|
$546.41
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
636J280501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$242.00 |
| Max. Negotiated Rate |
$519.09 |
| Rate for Payer: Aetna of VT Commercial |
$519.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$393.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$242.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$393.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$328.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$464.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$442.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$245.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$434.40
|
| Rate for Payer: Cash Price |
$273.20
|
| Rate for Payer: Cash Price |
$273.20
|
| Rate for Payer: Cigna Commercial |
$437.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$437.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$437.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$245.88
|
| Rate for Payer: Multiplan Commercial |
$508.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$464.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$245.88
|
| Rate for Payer: United Healthcare Commercial |
$519.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$245.88
|
| Rate for Payer: United Healthcare VA CCN |
$245.88
|
|
|
SKIN FUNGI CULTURE
|
Facility
|
IP
|
$167.09
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
3008710101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.66 |
| Max. Negotiated Rate |
$158.74 |
| Rate for Payer: Aetna of VT Commercial |
$158.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$123.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$123.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$142.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$133.67
|
| Rate for Payer: Cash Price |
$83.54
|
| Rate for Payer: Cigna Commercial |
$133.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$133.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$133.67
|
| Rate for Payer: Multiplan Commercial |
$155.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$142.03
|
| Rate for Payer: United Healthcare Commercial |
$158.74
|
|
|
SKIN FUNGI CULTURE
|
Professional
|
Both
|
$167.09
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
3008710101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$157.06 |
| Rate for Payer: Aetna of VT Commercial |
$157.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$37.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$37.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$10.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.19
|
| Rate for Payer: Cash Price |
$83.54
|
| Rate for Payer: Cash Price |
$83.54
|
| Rate for Payer: Cigna Commercial |
$9.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.60
|
| Rate for Payer: Multiplan Commercial |
$155.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.71
|
| Rate for Payer: United Healthcare Commercial |
$11.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.71
|
| Rate for Payer: United Healthcare VA CCN |
$7.71
|
|
|
SKIN FUNGI CULTURE
|
Facility
|
OP
|
$167.09
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
3008710101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$158.74 |
| Rate for Payer: Aetna of VT Commercial |
$158.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$37.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$74.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$37.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$100.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$142.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$135.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$75.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.84
|
| Rate for Payer: Cash Price |
$83.54
|
| Rate for Payer: Cash Price |
$83.54
|
| Rate for Payer: Cigna Commercial |
$133.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$133.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$133.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$75.19
|
| Rate for Payer: Multiplan Commercial |
$155.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$142.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$75.19
|
| Rate for Payer: United Healthcare Commercial |
$158.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.71
|
| Rate for Payer: United Healthcare VA CCN |
$75.19
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
IP
|
$5,034.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
5101527501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3,725.66 |
| Max. Negotiated Rate |
$4,782.30 |
| Rate for Payer: Aetna of VT Commercial |
$4,782.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,725.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,725.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,278.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,228.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,027.20
|
| Rate for Payer: Cash Price |
$2,517.00
|
| Rate for Payer: Cigna Commercial |
$4,027.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,027.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,027.20
|
| Rate for Payer: Multiplan Commercial |
$4,681.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,278.90
|
| Rate for Payer: United Healthcare Commercial |
$4,782.30
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
OP
|
$5,034.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
5101527501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,229.56 |
| Max. Negotiated Rate |
$4,782.30 |
| Rate for Payer: Aetna of VT Commercial |
$4,782.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,509.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,229.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,509.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,030.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,278.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,077.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,265.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,002.03
|
| Rate for Payer: Cash Price |
$2,517.00
|
| Rate for Payer: Cigna Commercial |
$4,027.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,027.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,027.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,265.30
|
| Rate for Payer: Multiplan Commercial |
$4,681.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,278.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,265.30
|
| Rate for Payer: United Healthcare Commercial |
$4,782.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,265.30
|
| Rate for Payer: United Healthcare VA CCN |
$2,265.30
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
IP
|
$5,547.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$4,105.33 |
| Max. Negotiated Rate |
$5,269.65 |
| Rate for Payer: Aetna of VT Commercial |
$5,269.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,105.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,105.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,714.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,659.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,437.60
|
| Rate for Payer: Cash Price |
$2,773.50
|
| Rate for Payer: Cigna Commercial |
$4,437.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,437.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,437.60
|
| Rate for Payer: Multiplan Commercial |
$5,158.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,714.95
|
| Rate for Payer: United Healthcare Commercial |
$5,269.65
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
OP
|
$5,547.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,456.77 |
| Max. Negotiated Rate |
$5,269.65 |
| Rate for Payer: Aetna of VT Commercial |
$5,269.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,969.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,456.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,969.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,339.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,714.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,493.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,496.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,409.86
|
| Rate for Payer: Cash Price |
$2,773.50
|
| Rate for Payer: Cigna Commercial |
$4,437.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,437.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,437.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,496.15
|
| Rate for Payer: Multiplan Commercial |
$5,158.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,714.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,496.15
|
| Rate for Payer: United Healthcare Commercial |
$5,269.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,496.15
|
| Rate for Payer: United Healthcare VA CCN |
$2,496.15
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Professional
|
Both
|
$5,547.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.58 |
| Max. Negotiated Rate |
$5,214.18 |
| Rate for Payer: Aetna of VT Commercial |
$5,214.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,969.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,969.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$100.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$222.24
|
| Rate for Payer: Cash Price |
$2,773.50
|
| Rate for Payer: Cash Price |
$2,773.50
|
| Rate for Payer: Cigna Commercial |
$97.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$244.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$244.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$5,158.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare Commercial |
$134.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare VA CCN |
$87.58
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
OP
|
$514.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$227.65 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Aetna of VT Commercial |
$488.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$227.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$309.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$436.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$416.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$231.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$408.63
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cigna Commercial |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$231.30
|
| Rate for Payer: Multiplan Commercial |
$478.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$436.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$231.30
|
| Rate for Payer: United Healthcare Commercial |
$488.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.30
|
| Rate for Payer: United Healthcare VA CCN |
$231.30
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.58 |
| Max. Negotiated Rate |
$483.16 |
| Rate for Payer: Aetna of VT Commercial |
$483.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$100.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$222.24
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cigna Commercial |
$97.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$244.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$244.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$478.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare Commercial |
$134.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare VA CCN |
$87.58
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Facility
|
IP
|
$514.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
9601527502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$380.41 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Aetna of VT Commercial |
$488.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$380.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$380.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$436.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$431.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.20
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cigna Commercial |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.20
|
| Rate for Payer: Multiplan Commercial |
$478.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$436.90
|
| Rate for Payer: United Healthcare Commercial |
$488.30
|
|
|
SKIN SUB GRAFT FACE/NK/HF/G
|
Professional
|
Both
|
$5,034.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
5101527501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.58 |
| Max. Negotiated Rate |
$4,731.96 |
| Rate for Payer: Aetna of VT Commercial |
$4,731.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,509.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,509.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$222.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$100.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$222.24
|
| Rate for Payer: Cash Price |
$2,517.00
|
| Rate for Payer: Cash Price |
$2,517.00
|
| Rate for Payer: Cigna Commercial |
$97.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$244.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$244.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$4,681.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$124.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare Commercial |
$134.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.58
|
| Rate for Payer: United Healthcare VA CCN |
$87.58
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
IP
|
$331.00
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
9601527101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$244.97 |
| Max. Negotiated Rate |
$314.45 |
| Rate for Payer: Aetna of VT Commercial |
$314.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$244.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$244.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$281.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$278.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$264.80
|
| Rate for Payer: Cash Price |
$165.50
|
| Rate for Payer: Cigna Commercial |
$264.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$264.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$264.80
|
| Rate for Payer: Multiplan Commercial |
$307.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$281.35
|
| Rate for Payer: United Healthcare Commercial |
$314.45
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
OP
|
$198.60
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
9601527102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$87.96 |
| Max. Negotiated Rate |
$188.67 |
| Rate for Payer: Aetna of VT Commercial |
$188.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$119.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$160.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$89.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.89
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$158.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$89.37
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$89.37
|
| Rate for Payer: United Healthcare Commercial |
$188.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.37
|
| Rate for Payer: United Healthcare VA CCN |
$89.37
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
OP
|
$331.00
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
9821527101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$146.60 |
| Max. Negotiated Rate |
$314.45 |
| Rate for Payer: Aetna of VT Commercial |
$314.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$296.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$146.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$296.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$281.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$268.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$148.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$263.14
|
| Rate for Payer: Cash Price |
$165.50
|
| Rate for Payer: Cigna Commercial |
$264.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$264.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$264.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$148.95
|
| Rate for Payer: Multiplan Commercial |
$307.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$281.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$148.95
|
| Rate for Payer: United Healthcare Commercial |
$314.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.95
|
| Rate for Payer: United Healthcare VA CCN |
$148.95
|
|
|
SKIN SUB GRAFT TRNK/ARM/LEG
|
Facility
|
IP
|
$198.60
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
9601527102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$146.98 |
| Max. Negotiated Rate |
$188.67 |
| Rate for Payer: Aetna of VT Commercial |
$188.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$146.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$146.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$166.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$158.88
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$158.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.88
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.81
|
| Rate for Payer: United Healthcare Commercial |
$188.67
|
|
