|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9812843001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9812843001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
OP
|
$129.25
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
4502843001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$57.24 |
| Max. Negotiated Rate |
$122.79 |
| Rate for Payer: Aetna of VT Commercial |
$122.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$115.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$115.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$109.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$104.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$102.75
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cigna Commercial |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$103.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$120.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$109.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$58.16
|
| Rate for Payer: United Healthcare Commercial |
$122.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$58.16
|
| Rate for Payer: United Healthcare VA CCN |
$58.16
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9812843001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$407.68 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$213.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$290.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$407.68
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$392.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$236.52
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare Commercial |
$319.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare VA CCN |
$207.61
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
5102350001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.28 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$79.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$142.31
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.55
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare VA CCN |
$80.55
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$340.10 |
| Rate for Payer: Aetna of VT Commercial |
$340.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$264.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$264.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$304.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$300.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$286.40
|
| Rate for Payer: Cash Price |
$179.00
|
| Rate for Payer: Cigna Commercial |
$286.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$286.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$286.40
|
| Rate for Payer: Multiplan Commercial |
$332.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$304.30
|
| Rate for Payer: United Healthcare Commercial |
$340.10
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$79.28 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$79.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$142.31
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.55
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare VA CCN |
$80.55
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$222.29 |
| Max. Negotiated Rate |
$428.76 |
| Rate for Payer: Aetna of VT Commercial |
$336.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$320.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$234.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$320.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$318.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$261.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$342.06
|
| Rate for Payer: Cash Price |
$179.00
|
| Rate for Payer: Cash Price |
$179.00
|
| Rate for Payer: Cigna Commercial |
$428.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$366.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$366.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$222.29
|
| Rate for Payer: Multiplan Commercial |
$332.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$323.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare Commercial |
$350.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare VA CCN |
$227.76
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
5102350001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.37 |
| Max. Negotiated Rate |
$428.76 |
| Rate for Payer: Aetna of VT Commercial |
$168.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$234.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$318.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$261.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$342.06
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$428.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$366.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$366.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$222.29
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$323.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare Commercial |
$350.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare VA CCN |
$227.76
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
5102350001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.48 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$150.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.20
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$160.37 |
| Max. Negotiated Rate |
$428.76 |
| Rate for Payer: Aetna of VT Commercial |
$168.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$234.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$318.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$342.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$261.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$342.06
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$428.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$366.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$366.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$222.29
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$323.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare Commercial |
$350.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.76
|
| Rate for Payer: United Healthcare VA CCN |
$227.76
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$132.48 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$150.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.20
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
|
|
CLTX CLAVICULAR FX W/O MNPJ
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 23500
|
| Hospital Charge Code |
9602350001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$158.56 |
| Max. Negotiated Rate |
$340.10 |
| Rate for Payer: Aetna of VT Commercial |
$340.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$320.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$158.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$320.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$215.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$304.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$289.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$161.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$284.61
|
| Rate for Payer: Cash Price |
$179.00
|
| Rate for Payer: Cigna Commercial |
$286.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$286.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$286.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$161.10
|
| Rate for Payer: Multiplan Commercial |
$332.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$304.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$161.10
|
| Rate for Payer: United Healthcare Commercial |
$340.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$161.10
|
| Rate for Payer: United Healthcare VA CCN |
$161.10
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
OP
|
$995.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778801
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$440.69 |
| Max. Negotiated Rate |
$945.25 |
| Rate for Payer: Aetna of VT Commercial |
$945.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$891.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$440.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$891.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$598.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$845.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$805.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$447.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$791.02
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$796.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$796.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$796.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$447.75
|
| Rate for Payer: Multiplan Commercial |
$925.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$845.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$447.75
|
| Rate for Payer: United Healthcare Commercial |
$945.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$447.75
|
| Rate for Payer: United Healthcare VA CCN |
$447.75
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
OP
|
$653.36
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
4502778801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$289.37 |
| Max. Negotiated Rate |
$620.69 |
| Rate for Payer: Aetna of VT Commercial |
$620.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$585.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$289.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$585.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$393.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$529.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$294.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$519.42
|
| Rate for Payer: Cash Price |
$326.68
|
| Rate for Payer: Cigna Commercial |
$522.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$522.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$522.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.01
|
| Rate for Payer: Multiplan Commercial |
$607.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$294.01
|
| Rate for Payer: United Healthcare Commercial |
$620.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.01
|
| Rate for Payer: United Healthcare VA CCN |
$294.01
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
OP
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9822778801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$289.66 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Aetna of VT Commercial |
$621.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$289.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$393.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$529.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$294.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$519.93
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$523.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.30
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$294.30
|
| Rate for Payer: United Healthcare Commercial |
$621.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.30
|
| Rate for Payer: United Healthcare VA CCN |
$294.30
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
OP
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778802
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$289.66 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Aetna of VT Commercial |
$621.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$289.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$393.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$529.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$294.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$519.93
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$523.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.30
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$294.30
|
| Rate for Payer: United Healthcare Commercial |
$621.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.30
|
| Rate for Payer: United Healthcare VA CCN |
$294.30
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
IP
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9822778801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$484.03 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Aetna of VT Commercial |
$621.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$484.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$484.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$549.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$523.20
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$523.20
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.90
|
| Rate for Payer: United Healthcare Commercial |
$621.30
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Professional
|
Both
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778802
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$374.10 |
| Max. Negotiated Rate |
$708.81 |
| Rate for Payer: Aetna of VT Commercial |
$614.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$385.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$523.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$430.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$643.54
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$708.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$685.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$685.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$415.54
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$531.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare Commercial |
$575.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare VA CCN |
$374.10
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Professional
|
Both
|
$995.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778801
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$374.10 |
| Max. Negotiated Rate |
$935.30 |
| Rate for Payer: Aetna of VT Commercial |
$935.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$891.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$385.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$891.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$523.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$430.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$643.54
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$708.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$685.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$685.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$415.54
|
| Rate for Payer: Multiplan Commercial |
$925.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$531.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare Commercial |
$575.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare VA CCN |
$374.10
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
IP
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778802
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$484.03 |
| Max. Negotiated Rate |
$621.30 |
| Rate for Payer: Aetna of VT Commercial |
$621.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$484.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$484.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$549.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$523.20
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$523.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$523.20
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.90
|
| Rate for Payer: United Healthcare Commercial |
$621.30
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Professional
|
Both
|
$654.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9822778801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$374.10 |
| Max. Negotiated Rate |
$708.81 |
| Rate for Payer: Aetna of VT Commercial |
$614.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$385.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$585.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$523.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$643.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$430.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$643.54
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cash Price |
$327.00
|
| Rate for Payer: Cigna Commercial |
$708.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$685.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$685.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$415.54
|
| Rate for Payer: Multiplan Commercial |
$608.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$531.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare Commercial |
$575.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$374.10
|
| Rate for Payer: United Healthcare VA CCN |
$374.10
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
IP
|
$995.00
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
9812778801
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$736.40 |
| Max. Negotiated Rate |
$945.25 |
| Rate for Payer: Aetna of VT Commercial |
$945.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$736.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$736.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$845.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$835.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$796.00
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$796.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$796.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$796.00
|
| Rate for Payer: Multiplan Commercial |
$925.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$845.75
|
| Rate for Payer: United Healthcare Commercial |
$945.25
|
|
|
CLTX DSTL FIBULAR FX LAT MALLS
|
Facility
|
IP
|
$653.36
|
|
|
Service Code
|
CPT 27788
|
| Hospital Charge Code |
4502778801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$483.55 |
| Max. Negotiated Rate |
$620.69 |
| Rate for Payer: Aetna of VT Commercial |
$620.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$483.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$483.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$555.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$548.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$522.69
|
| Rate for Payer: Cash Price |
$326.68
|
| Rate for Payer: Cigna Commercial |
$522.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$522.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$522.69
|
| Rate for Payer: Multiplan Commercial |
$607.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$555.36
|
| Rate for Payer: United Healthcare Commercial |
$620.69
|
|
|
CLTX GR HMRL TBRS FX WO MNPJ
|
Professional
|
Both
|
$981.00
|
|
|
Service Code
|
CPT 23620
|
| Hospital Charge Code |
9602362001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$257.89 |
| Max. Negotiated Rate |
$922.14 |
| Rate for Payer: Aetna of VT Commercial |
$922.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$878.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$265.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$878.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$433.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$433.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$296.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$433.93
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$486.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$443.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$443.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$269.77
|
| Rate for Payer: Multiplan Commercial |
$912.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$366.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$257.89
|
| Rate for Payer: United Healthcare Commercial |
$396.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.89
|
| Rate for Payer: United Healthcare VA CCN |
$257.89
|
|
