|
US OB US LIMITED 1/> FETUSES
|
Facility
|
OP
|
$562.75
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
4027681501
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$219.43 |
| Max. Negotiated Rate |
$534.61 |
| Rate for Payer: Aetna of VT Commercial |
$534.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$219.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$249.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$219.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$338.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$478.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$455.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$253.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$447.39
|
| Rate for Payer: Cash Price |
$281.38
|
| Rate for Payer: Cash Price |
$281.38
|
| Rate for Payer: Cigna Commercial |
$450.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$450.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$450.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$253.24
|
| Rate for Payer: Multiplan Commercial |
$523.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$478.34
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$253.24
|
| Rate for Payer: United Healthcare Commercial |
$534.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$253.24
|
| Rate for Payer: United Healthcare VA CCN |
$253.24
|
|
|
US OB US TRANSVAGINAL
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 76817 26
|
| Hospital Charge Code |
9727681701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$412.24 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna of VT Commercial |
$529.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$412.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$412.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$473.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$467.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$445.60
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$445.60
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$473.45
|
| Rate for Payer: United Healthcare Commercial |
$529.15
|
|
|
US OB US TRANSVAGINAL
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 76817 26
|
| Hospital Charge Code |
9727681701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$246.70 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna of VT Commercial |
$529.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$246.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$335.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$473.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$451.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$250.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$442.81
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$445.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$250.65
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$473.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.65
|
| Rate for Payer: United Healthcare Commercial |
$529.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.65
|
| Rate for Payer: United Healthcare VA CCN |
$250.65
|
|
|
US OB US TRANSVAGINAL
|
Facility
|
OP
|
$656.59
|
|
|
Service Code
|
CPT 76817
|
| Hospital Charge Code |
4027681701
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$248.33 |
| Max. Negotiated Rate |
$623.76 |
| Rate for Payer: Aetna of VT Commercial |
$623.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$248.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$290.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$248.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$395.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$558.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$531.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$295.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$521.99
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: Cigna Commercial |
$525.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$525.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$525.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$295.47
|
| Rate for Payer: Multiplan Commercial |
$610.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$558.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$295.47
|
| Rate for Payer: United Healthcare Commercial |
$623.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.47
|
| Rate for Payer: United Healthcare VA CCN |
$295.47
|
|
|
US OB US TRANSVAGINAL
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 76817 26
|
| Hospital Charge Code |
9727681701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$33.76 |
| Max. Negotiated Rate |
$523.58 |
| Rate for Payer: Aetna of VT Commercial |
$523.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$248.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$248.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$47.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$57.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$57.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$57.91
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$51.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.76
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.76
|
| Rate for Payer: United Healthcare Commercial |
$51.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.76
|
| Rate for Payer: United Healthcare VA CCN |
$33.76
|
|
|
US OB US TRANSVAGINAL
|
Facility
|
IP
|
$656.59
|
|
|
Service Code
|
CPT 76817
|
| Hospital Charge Code |
4027681701
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$485.94 |
| Max. Negotiated Rate |
$623.76 |
| Rate for Payer: Aetna of VT Commercial |
$623.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$485.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$485.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$558.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$551.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$525.27
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: Cigna Commercial |
$525.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$525.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$525.27
|
| Rate for Payer: Multiplan Commercial |
$610.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$558.10
|
| Rate for Payer: United Healthcare Commercial |
$623.76
|
|
|
US PELVIC COMPLETE NONOB
|
Facility
|
OP
|
$779.64
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
4027685601
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$317.67 |
| Max. Negotiated Rate |
$740.66 |
| Rate for Payer: Aetna of VT Commercial |
$740.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$317.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$345.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$317.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$469.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$662.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$631.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$350.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$619.81
|
| Rate for Payer: Cash Price |
$389.82
|
| Rate for Payer: Cash Price |
$389.82
|
| Rate for Payer: Cigna Commercial |
$623.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$623.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$623.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$350.84
|
| Rate for Payer: Multiplan Commercial |
$725.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$662.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$350.84
|
| Rate for Payer: United Healthcare Commercial |
$740.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$350.84
|
| Rate for Payer: United Healthcare VA CCN |
$350.84
|
|
|
US PELVIC COMPLETE NONOB
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 76856 26
|
| Hospital Charge Code |
9727685601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$114.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$114.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$155.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$209.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$116.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.91
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$116.55
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare VA CCN |
$116.55
|
|
|
US PELVIC COMPLETE NONOB
|
Facility
|
IP
|
$779.64
|
|
|
Service Code
|
CPT 76856
|
| Hospital Charge Code |
4027685601
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$577.01 |
| Max. Negotiated Rate |
$740.66 |
| Rate for Payer: Aetna of VT Commercial |
$740.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$577.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$577.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$662.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$654.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$623.71
|
| Rate for Payer: Cash Price |
$389.82
|
| Rate for Payer: Cigna Commercial |
$623.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$623.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$623.71
|
| Rate for Payer: Multiplan Commercial |
$725.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$662.69
|
| Rate for Payer: United Healthcare Commercial |
$740.66
|
|
|
US PELVIC COMPLETE NONOB
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 76856 26
|
| Hospital Charge Code |
9727685601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$191.69 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$217.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$207.20
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
|
|
US PELVIC LIMITED /FOLLOWUP
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT 76857 26
|
| Hospital Charge Code |
9727685701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$122.86 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna of VT Commercial |
$157.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.80
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.80
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.10
|
| Rate for Payer: United Healthcare Commercial |
$157.70
|
|
|
US PELVIC LIMITED /FOLLOWUP
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 76857 26
|
| Hospital Charge Code |
9727685701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$22.29 |
| Max. Negotiated Rate |
$156.04 |
| Rate for Payer: Aetna of VT Commercial |
$156.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$22.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$58.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$25.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.34
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$33.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.29
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$31.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.29
|
| Rate for Payer: United Healthcare Commercial |
$34.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.29
|
| Rate for Payer: United Healthcare VA CCN |
$22.29
|
|
|
US PELVIC LIMITED /FOLLOWUP
|
Facility
|
IP
|
$638.24
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
4027685701
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$472.36 |
| Max. Negotiated Rate |
$606.33 |
| Rate for Payer: Aetna of VT Commercial |
$606.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$472.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$472.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$542.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$536.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$510.59
|
| Rate for Payer: Cash Price |
$319.12
|
| Rate for Payer: Cigna Commercial |
$510.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$510.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$510.59
|
| Rate for Payer: Multiplan Commercial |
$593.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$542.50
|
| Rate for Payer: United Healthcare Commercial |
$606.33
|
|
|
US PELVIC LIMITED /FOLLOWUP
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 76857 26
|
| Hospital Charge Code |
9727685701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$73.52 |
| Max. Negotiated Rate |
$157.70 |
| Rate for Payer: Aetna of VT Commercial |
$157.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.97
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.70
|
| Rate for Payer: Multiplan Commercial |
$154.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.70
|
| Rate for Payer: United Healthcare Commercial |
$157.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.70
|
| Rate for Payer: United Healthcare VA CCN |
$74.70
|
|
|
US PELVIC LIMITED /FOLLOWUP
|
Facility
|
OP
|
$638.24
|
|
|
Service Code
|
CPT 76857
|
| Hospital Charge Code |
4027685701
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$113.94 |
| Max. Negotiated Rate |
$606.33 |
| Rate for Payer: Aetna of VT Commercial |
$606.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$282.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$384.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$542.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$516.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$287.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$507.40
|
| Rate for Payer: Cash Price |
$319.12
|
| Rate for Payer: Cash Price |
$319.12
|
| Rate for Payer: Cigna Commercial |
$510.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$510.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$510.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$287.21
|
| Rate for Payer: Multiplan Commercial |
$593.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$542.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$287.21
|
| Rate for Payer: United Healthcare Commercial |
$606.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$287.21
|
| Rate for Payer: United Healthcare VA CCN |
$287.21
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
OP
|
$1,197.00
|
|
|
Service Code
|
CPT 19285 26
|
| Hospital Charge Code |
9721928501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$530.15 |
| Max. Negotiated Rate |
$1,137.15 |
| Rate for Payer: Aetna of VT Commercial |
$1,137.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,072.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$530.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,072.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$720.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,017.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$969.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$538.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$951.62
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$957.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$957.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$957.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$538.65
|
| Rate for Payer: Multiplan Commercial |
$1,113.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,017.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$538.65
|
| Rate for Payer: United Healthcare Commercial |
$1,137.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$538.65
|
| Rate for Payer: United Healthcare VA CCN |
$538.65
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
IP
|
$536.77
|
|
|
Service Code
|
CPT 19285 RT
|
| Hospital Charge Code |
40219285RT
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$397.26 |
| Max. Negotiated Rate |
$509.93 |
| Rate for Payer: Aetna of VT Commercial |
$509.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$456.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$450.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$429.42
|
| Rate for Payer: Cash Price |
$268.38
|
| Rate for Payer: Cigna Commercial |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$429.42
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$456.25
|
| Rate for Payer: United Healthcare Commercial |
$509.93
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
IP
|
$1,197.00
|
|
|
Service Code
|
CPT 19285 26
|
| Hospital Charge Code |
9721928501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$885.90 |
| Max. Negotiated Rate |
$1,137.15 |
| Rate for Payer: Aetna of VT Commercial |
$1,137.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,017.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,005.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$957.60
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$957.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$957.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$957.60
|
| Rate for Payer: Multiplan Commercial |
$1,113.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,017.45
|
| Rate for Payer: United Healthcare Commercial |
$1,137.15
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
OP
|
$536.77
|
|
|
Service Code
|
CPT 19285 RT
|
| Hospital Charge Code |
40219285RT
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$237.74 |
| Max. Negotiated Rate |
$509.93 |
| Rate for Payer: Aetna of VT Commercial |
$509.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$480.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$237.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$480.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$323.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$456.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$434.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$241.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$426.73
|
| Rate for Payer: Cash Price |
$268.38
|
| Rate for Payer: Cigna Commercial |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$429.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$241.55
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$456.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$241.55
|
| Rate for Payer: United Healthcare Commercial |
$509.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.55
|
| Rate for Payer: United Healthcare VA CCN |
$241.55
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
IP
|
$536.77
|
|
|
Service Code
|
CPT 19285 LT
|
| Hospital Charge Code |
40219285LT
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$397.26 |
| Max. Negotiated Rate |
$509.93 |
| Rate for Payer: Aetna of VT Commercial |
$509.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$456.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$450.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$429.42
|
| Rate for Payer: Cash Price |
$268.38
|
| Rate for Payer: Cigna Commercial |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$429.42
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$456.25
|
| Rate for Payer: United Healthcare Commercial |
$509.93
|
|
|
US PERQ BREAST LOC DEV 1ST LES
|
Facility
|
OP
|
$536.77
|
|
|
Service Code
|
CPT 19285 LT
|
| Hospital Charge Code |
40219285LT
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$237.74 |
| Max. Negotiated Rate |
$509.93 |
| Rate for Payer: Aetna of VT Commercial |
$509.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$480.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$237.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$480.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$323.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$456.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$434.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$241.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$426.73
|
| Rate for Payer: Cash Price |
$268.38
|
| Rate for Payer: Cigna Commercial |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$429.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$429.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$241.55
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$456.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$241.55
|
| Rate for Payer: United Healthcare Commercial |
$509.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.55
|
| Rate for Payer: United Healthcare VA CCN |
$241.55
|
|
|
US PROSTATE BIOPSY 18GX20CM
|
Facility
|
IP
|
$165.23
|
|
| Hospital Charge Code |
2720020731
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$122.29 |
| Max. Negotiated Rate |
$156.97 |
| Rate for Payer: Aetna of VT Commercial |
$156.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$140.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.18
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Cigna Commercial |
$132.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.18
|
| Rate for Payer: Multiplan Commercial |
$153.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$140.45
|
| Rate for Payer: United Healthcare Commercial |
$156.97
|
|
|
US PROSTATE BIOPSY 18GX20CM
|
Facility
|
OP
|
$165.23
|
|
| Hospital Charge Code |
2720020731
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.18 |
| Max. Negotiated Rate |
$156.97 |
| Rate for Payer: Aetna of VT Commercial |
$156.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$140.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$133.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.36
|
| Rate for Payer: Cash Price |
$82.61
|
| Rate for Payer: Cigna Commercial |
$132.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.35
|
| Rate for Payer: Multiplan Commercial |
$153.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$140.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.35
|
| Rate for Payer: United Healthcare Commercial |
$156.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.35
|
| Rate for Payer: United Healthcare VA CCN |
$74.35
|
|
|
US PRQ BRST LOC DEV EA ADD LES
|
Facility
|
OP
|
$1,005.00
|
|
|
Service Code
|
CPT 19286 26
|
| Hospital Charge Code |
9721928601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$445.11 |
| Max. Negotiated Rate |
$954.75 |
| Rate for Payer: Aetna of VT Commercial |
$954.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$900.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$445.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$900.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$605.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$854.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$814.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$452.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$798.98
|
| Rate for Payer: Cash Price |
$502.50
|
| Rate for Payer: Cigna Commercial |
$804.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$804.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$804.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$452.25
|
| Rate for Payer: Multiplan Commercial |
$934.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$854.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$452.25
|
| Rate for Payer: United Healthcare Commercial |
$954.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$452.25
|
| Rate for Payer: United Healthcare VA CCN |
$452.25
|
|
|
US PRQ BRST LOC DEV EA ADD LES
|
Facility
|
OP
|
$316.20
|
|
|
Service Code
|
CPT 19286
|
| Hospital Charge Code |
4021928601
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$140.04 |
| Max. Negotiated Rate |
$300.39 |
| Rate for Payer: Aetna of VT Commercial |
$300.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$283.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$140.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$283.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$190.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$256.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$251.38
|
| Rate for Payer: Cash Price |
$158.10
|
| Rate for Payer: Cigna Commercial |
$252.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.29
|
| Rate for Payer: Multiplan Commercial |
$294.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.29
|
| Rate for Payer: United Healthcare Commercial |
$300.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.29
|
| Rate for Payer: United Healthcare VA CCN |
$142.29
|
|
