|
TISSUE EXAM FOR FUNGI
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
300872200
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.02 |
| 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 |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
|
|
TISSUE EXAM FOR FUNGI
|
Professional
|
Both
|
$19.65
|
|
| Hospital Charge Code |
3008722001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$18.47 |
| Rate for Payer: Aetna of VT Commercial |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.60
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Multiplan Commercial |
$18.27
|
| Rate for Payer: United Healthcare Commercial |
$16.70
|
| Rate for Payer: United Healthcare VA CCN |
$7.86
|
|
|
TISSUE EXAM FOR FUNGI
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
300872200
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$21.04 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$21.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$21.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
TISSUE EXAM FOR FUNGI
|
Facility
|
IP
|
$19.65
|
|
| Hospital Charge Code |
3008722001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.54 |
| Max. Negotiated Rate |
$18.67 |
| Rate for Payer: Aetna of VT Commercial |
$18.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$14.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$14.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$15.72
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna Commercial |
$15.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.72
|
| Rate for Payer: Multiplan Commercial |
$18.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.70
|
| Rate for Payer: United Healthcare Commercial |
$18.67
|
|
|
TISSUE EXAM FOR FUNGI
|
Facility
|
OP
|
$19.65
|
|
| Hospital Charge Code |
3008722001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$18.67 |
| Rate for Payer: Aetna of VT Commercial |
$18.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$11.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$15.62
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna Commercial |
$15.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.84
|
| Rate for Payer: Multiplan Commercial |
$18.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$18.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.84
|
| Rate for Payer: United Healthcare VA CCN |
$8.84
|
|
|
TISSUE HOMOGENIZATION CULTR
|
Facility
|
OP
|
$28.57
|
|
|
Service Code
|
CPT 87176
|
| Hospital Charge Code |
3008717601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna of VT Commercial |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.71
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cigna Commercial |
$22.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.86
|
| Rate for Payer: Multiplan Commercial |
$26.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.86
|
| Rate for Payer: United Healthcare Commercial |
$27.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.88
|
| Rate for Payer: United Healthcare VA CCN |
$12.86
|
|
|
TISSUE HOMOGENIZATION CULTR
|
Facility
|
IP
|
$28.57
|
|
|
Service Code
|
CPT 87176
|
| Hospital Charge Code |
3008717601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.14 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna of VT Commercial |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$21.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$21.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.86
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cigna Commercial |
$22.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.86
|
| Rate for Payer: Multiplan Commercial |
$26.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.28
|
| Rate for Payer: United Healthcare Commercial |
$27.14
|
|
|
TISSUE HOMOGENIZATION CULTR
|
Professional
|
Both
|
$28.57
|
|
|
Service Code
|
CPT 87176
|
| Hospital Charge Code |
3008717601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Aetna of VT Commercial |
$26.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$8.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$8.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$6.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.56
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cigna Commercial |
$7.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$5.80
|
| Rate for Payer: Multiplan Commercial |
$26.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.88
|
| Rate for Payer: United Healthcare Commercial |
$9.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.88
|
| Rate for Payer: United Healthcare VA CCN |
$5.88
|
|
|
TISSUE MEND 5X6CM
|
Facility
|
OP
|
$3,087.52
|
|
| Hospital Charge Code |
2780037591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,367.46 |
| Max. Negotiated Rate |
$2,933.14 |
| Rate for Payer: Aetna of VT Commercial |
$2,933.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,766.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,367.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,766.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,858.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,624.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,500.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,389.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,454.58
|
| Rate for Payer: Cash Price |
$1,543.76
|
| Rate for Payer: Cigna Commercial |
$2,470.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,470.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,470.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,389.38
|
| Rate for Payer: Multiplan Commercial |
$2,871.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,624.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,389.38
|
| Rate for Payer: United Healthcare Commercial |
$2,933.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,389.38
|
| Rate for Payer: United Healthcare VA CCN |
$1,389.38
|
|
|
TISSUE MEND 5X6CM
|
Facility
|
IP
|
$3,087.52
|
|
| Hospital Charge Code |
2780037591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,285.07 |
| Max. Negotiated Rate |
$2,933.14 |
| Rate for Payer: Aetna of VT Commercial |
$2,933.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,285.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,285.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,624.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,593.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,470.02
|
| Rate for Payer: Cash Price |
$1,543.76
|
| Rate for Payer: Cigna Commercial |
$2,470.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,470.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,470.02
|
| Rate for Payer: Multiplan Commercial |
$2,871.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,624.39
|
| Rate for Payer: United Healthcare Commercial |
$2,933.14
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$5,103.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,776.73 |
| Max. Negotiated Rate |
$4,847.85 |
| Rate for Payer: Aetna of VT Commercial |
$4,847.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,776.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,776.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,337.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,286.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,082.40
|
| Rate for Payer: Cash Price |
$2,551.50
|
| Rate for Payer: Cigna Commercial |
$4,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,082.40
|
| Rate for Payer: Multiplan Commercial |
$4,745.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,337.55
|
| Rate for Payer: United Healthcare Commercial |
$4,847.85
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
OP
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9821404001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$897.32 |
| Max. Negotiated Rate |
$1,924.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,924.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$897.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,219.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,722.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,641.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$911.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,610.67
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,620.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$911.70
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,722.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$911.70
|
| Rate for Payer: United Healthcare Commercial |
$1,924.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$911.70
|
| Rate for Payer: United Healthcare VA CCN |
$911.70
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
OP
|
$5,103.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,260.12 |
| Max. Negotiated Rate |
$4,847.85 |
| Rate for Payer: Aetna of VT Commercial |
$4,847.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,571.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,260.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,571.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,072.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,337.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,133.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,296.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,056.89
|
| Rate for Payer: Cash Price |
$2,551.50
|
| Rate for Payer: Cigna Commercial |
$4,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,082.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,082.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,296.35
|
| Rate for Payer: Multiplan Commercial |
$4,745.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,337.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,296.35
|
| Rate for Payer: United Healthcare Commercial |
$4,847.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,296.35
|
| Rate for Payer: United Healthcare VA CCN |
$2,296.35
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Professional
|
Both
|
$5,103.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$591.96 |
| Max. Negotiated Rate |
$4,796.82 |
| Rate for Payer: Aetna of VT Commercial |
$4,796.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,571.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$609.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,571.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$828.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$680.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,029.10
|
| Rate for Payer: Cash Price |
$2,551.50
|
| Rate for Payer: Cash Price |
$2,551.50
|
| Rate for Payer: Cigna Commercial |
$663.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,183.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,183.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$724.30
|
| Rate for Payer: Multiplan Commercial |
$4,745.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$840.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare Commercial |
$910.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare VA CCN |
$591.96
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,499.44 |
| Max. Negotiated Rate |
$1,924.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,924.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,499.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,499.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,722.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,701.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,620.80
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,620.80
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,722.10
|
| Rate for Payer: United Healthcare Commercial |
$1,924.70
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
OP
|
$3,078.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
5101404001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,363.25 |
| Max. Negotiated Rate |
$2,924.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,924.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,757.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,363.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,757.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,852.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,616.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,493.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,385.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,447.01
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$2,462.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,462.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,462.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,385.10
|
| Rate for Payer: Multiplan Commercial |
$2,862.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,616.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,385.10
|
| Rate for Payer: United Healthcare Commercial |
$2,924.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,385.10
|
| Rate for Payer: United Healthcare VA CCN |
$1,385.10
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$3,078.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
5101404001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,278.03 |
| Max. Negotiated Rate |
$2,924.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,924.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,278.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,278.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,616.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,585.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,462.40
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$2,462.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,462.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,462.40
|
| Rate for Payer: Multiplan Commercial |
$2,862.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,616.30
|
| Rate for Payer: United Healthcare Commercial |
$2,924.10
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Professional
|
Both
|
$3,078.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
5101404001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$591.96 |
| Max. Negotiated Rate |
$2,893.32 |
| Rate for Payer: Aetna of VT Commercial |
$2,893.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,757.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$609.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,757.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$828.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$680.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,029.10
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$663.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,183.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,183.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$724.30
|
| Rate for Payer: Multiplan Commercial |
$2,862.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$840.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare Commercial |
$910.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare VA CCN |
$591.96
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Professional
|
Both
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9821404001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$591.96 |
| Max. Negotiated Rate |
$1,904.44 |
| Rate for Payer: Aetna of VT Commercial |
$1,904.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$609.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$828.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$680.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,029.10
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$663.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,183.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,183.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$724.30
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$840.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare Commercial |
$910.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare VA CCN |
$591.96
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Professional
|
Both
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$591.96 |
| Max. Negotiated Rate |
$1,904.44 |
| Rate for Payer: Aetna of VT Commercial |
$1,904.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$609.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$828.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,029.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$680.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,029.10
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$663.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,183.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,183.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$724.30
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$840.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare Commercial |
$910.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$591.96
|
| Rate for Payer: United Healthcare VA CCN |
$591.96
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9821404001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,499.44 |
| Max. Negotiated Rate |
$1,924.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,924.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,499.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,499.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,722.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,701.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,620.80
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,620.80
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,722.10
|
| Rate for Payer: United Healthcare Commercial |
$1,924.70
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
OP
|
$2,026.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
9601404002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$897.32 |
| Max. Negotiated Rate |
$1,924.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,924.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$897.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,815.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,219.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,722.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,641.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$911.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,610.67
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,620.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,620.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$911.70
|
| Rate for Payer: Multiplan Commercial |
$1,884.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,722.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$911.70
|
| Rate for Payer: United Healthcare Commercial |
$1,924.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$911.70
|
| Rate for Payer: United Healthcare VA CCN |
$911.70
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
IP
|
$2,437.00
|
|
|
Service Code
|
CPT 58570
|
| Hospital Charge Code |
9825857001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,803.62 |
| Max. Negotiated Rate |
$2,315.15 |
| Rate for Payer: Aetna of VT Commercial |
$2,315.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,803.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,803.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,071.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,047.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,949.60
|
| Rate for Payer: Cash Price |
$1,218.50
|
| Rate for Payer: Cigna Commercial |
$1,949.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,949.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,949.60
|
| Rate for Payer: Multiplan Commercial |
$2,266.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,071.45
|
| Rate for Payer: United Healthcare Commercial |
$2,315.15
|
|
|
TLH UTERUS 250 G OR LESS
|
Facility
|
OP
|
$2,437.00
|
|
|
Service Code
|
CPT 58570
|
| Hospital Charge Code |
9825857001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,079.35 |
| Max. Negotiated Rate |
$2,315.15 |
| Rate for Payer: Aetna of VT Commercial |
$2,315.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,183.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,079.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,183.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,467.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,071.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,973.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,096.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,937.41
|
| Rate for Payer: Cash Price |
$1,218.50
|
| Rate for Payer: Cigna Commercial |
$1,949.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,949.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,949.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,096.65
|
| Rate for Payer: Multiplan Commercial |
$2,266.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,071.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,096.65
|
| Rate for Payer: United Healthcare Commercial |
$2,315.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,096.65
|
| Rate for Payer: United Healthcare VA CCN |
$1,096.65
|
|
|
TLH UTERUS 250 G OR LESS
|
Professional
|
Both
|
$2,437.00
|
|
|
Service Code
|
CPT 58570
|
| Hospital Charge Code |
9825857001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$2,290.78 |
| Rate for Payer: Aetna of VT Commercial |
$2,290.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,183.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$774.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,183.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,052.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,099.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,099.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$864.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,099.56
|
| Rate for Payer: Cash Price |
$1,218.50
|
| Rate for Payer: Cash Price |
$1,218.50
|
| Rate for Payer: Cigna Commercial |
$1,325.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,253.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,253.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$751.52
|
| Rate for Payer: Multiplan Commercial |
$2,266.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,067.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$751.53
|
| Rate for Payer: United Healthcare Commercial |
$1,156.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$751.53
|
| Rate for Payer: United Healthcare VA CCN |
$751.53
|
|
