|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Facility
|
OP
|
$1,067.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
9602360502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$472.57 |
| Max. Negotiated Rate |
$1,013.65 |
| Rate for Payer: Aetna of VT Commercial |
$1,013.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$472.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$642.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$906.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$864.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$480.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$848.26
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cigna Commercial |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$853.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$480.15
|
| Rate for Payer: Multiplan Commercial |
$992.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$906.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$480.15
|
| Rate for Payer: United Healthcare Commercial |
$1,013.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$480.15
|
| Rate for Payer: United Healthcare VA CCN |
$480.15
|
|
|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Facility
|
IP
|
$1,067.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
9602360502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$789.69 |
| Max. Negotiated Rate |
$1,013.65 |
| Rate for Payer: Aetna of VT Commercial |
$1,013.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$789.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$789.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$906.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$896.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$853.60
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cigna Commercial |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$853.60
|
| Rate for Payer: Multiplan Commercial |
$992.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$906.95
|
| Rate for Payer: United Healthcare Commercial |
$1,013.65
|
|
|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Professional
|
Both
|
$2,208.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
9602360501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$414.12 |
| Max. Negotiated Rate |
$2,075.52 |
| Rate for Payer: Aetna of VT Commercial |
$2,075.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,978.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$426.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,978.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$579.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$730.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$730.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$476.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$730.66
|
| Rate for Payer: Cash Price |
$1,104.00
|
| Rate for Payer: Cash Price |
$1,104.00
|
| Rate for Payer: Cigna Commercial |
$785.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$757.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$757.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$458.13
|
| Rate for Payer: Multiplan Commercial |
$2,053.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$588.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$414.12
|
| Rate for Payer: United Healthcare Commercial |
$637.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$414.12
|
| Rate for Payer: United Healthcare VA CCN |
$414.12
|
|
|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Facility
|
OP
|
$1,067.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
9822360501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$472.57 |
| Max. Negotiated Rate |
$1,013.65 |
| Rate for Payer: Aetna of VT Commercial |
$1,013.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$472.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$642.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$906.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$864.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$480.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$848.26
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cigna Commercial |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$853.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$853.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$480.15
|
| Rate for Payer: Multiplan Commercial |
$992.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$906.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$480.15
|
| Rate for Payer: United Healthcare Commercial |
$1,013.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$480.15
|
| Rate for Payer: United Healthcare VA CCN |
$480.15
|
|
|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Professional
|
Both
|
$1,067.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
9822360501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$414.12 |
| Max. Negotiated Rate |
$1,002.98 |
| Rate for Payer: Aetna of VT Commercial |
$1,002.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$426.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$955.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$579.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$730.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$730.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$476.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$730.66
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cash Price |
$533.50
|
| Rate for Payer: Cigna Commercial |
$785.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$757.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$757.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$458.13
|
| Rate for Payer: Multiplan Commercial |
$992.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$588.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$414.12
|
| Rate for Payer: United Healthcare Commercial |
$637.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$414.12
|
| Rate for Payer: United Healthcare VA CCN |
$414.12
|
|
|
CLTX PRX HMRL FX MNPJ+-TRACT
|
Facility
|
IP
|
$1,142.00
|
|
|
Service Code
|
CPT 23605
|
| Hospital Charge Code |
5102360501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$845.19 |
| Max. Negotiated Rate |
$1,084.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,084.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$845.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$845.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$970.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$959.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$913.60
|
| Rate for Payer: Cash Price |
$571.00
|
| Rate for Payer: Cigna Commercial |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$913.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$913.60
|
| Rate for Payer: Multiplan Commercial |
$1,062.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$970.70
|
| Rate for Payer: United Healthcare Commercial |
$1,084.90
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Professional
|
Both
|
$614.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$233.26 |
| Max. Negotiated Rate |
$577.16 |
| Rate for Payer: Aetna of VT Commercial |
$577.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$550.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$248.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$550.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$338.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$277.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.86
|
| Rate for Payer: Cash Price |
$307.00
|
| Rate for Payer: Cash Price |
$307.00
|
| Rate for Payer: Cigna Commercial |
$454.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$384.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$384.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$233.26
|
| Rate for Payer: Multiplan Commercial |
$571.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$343.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare Commercial |
$371.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare VA CCN |
$241.62
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
OP
|
$614.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$271.94 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Aetna of VT Commercial |
$583.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$550.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$271.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$550.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$369.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$521.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$497.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$276.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.13
|
| Rate for Payer: Cash Price |
$307.00
|
| Rate for Payer: Cigna Commercial |
$491.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$491.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$491.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$276.30
|
| Rate for Payer: Multiplan Commercial |
$571.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$521.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$276.30
|
| Rate for Payer: United Healthcare Commercial |
$583.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$276.30
|
| Rate for Payer: United Healthcare VA CCN |
$276.30
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Professional
|
Both
|
$917.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$233.26 |
| Max. Negotiated Rate |
$861.98 |
| Rate for Payer: Aetna of VT Commercial |
$861.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$821.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$248.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$821.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$338.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$277.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.86
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$454.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$384.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$384.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$233.26
|
| Rate for Payer: Multiplan Commercial |
$852.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$343.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare Commercial |
$371.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare VA CCN |
$241.62
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
5102357001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$233.26 |
| Max. Negotiated Rate |
$454.95 |
| Rate for Payer: Aetna of VT Commercial |
$285.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$248.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$338.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$277.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.86
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$454.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$384.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$384.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$233.26
|
| Rate for Payer: Multiplan Commercial |
$282.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$343.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare Commercial |
$371.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.62
|
| Rate for Payer: United Healthcare VA CCN |
$241.62
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
IP
|
$614.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$454.42 |
| Max. Negotiated Rate |
$583.30 |
| Rate for Payer: Aetna of VT Commercial |
$583.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$454.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$454.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$521.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$515.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$491.20
|
| Rate for Payer: Cash Price |
$307.00
|
| Rate for Payer: Cigna Commercial |
$491.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$491.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$491.20
|
| Rate for Payer: Multiplan Commercial |
$571.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$521.90
|
| Rate for Payer: United Healthcare Commercial |
$583.30
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
5102357001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$224.99 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna of VT Commercial |
$288.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$224.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$224.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$255.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$243.20
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$243.20
|
| Rate for Payer: Multiplan Commercial |
$282.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.40
|
| Rate for Payer: United Healthcare Commercial |
$288.80
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
IP
|
$917.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$678.67 |
| Max. Negotiated Rate |
$871.15 |
| Rate for Payer: Aetna of VT Commercial |
$871.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$678.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$678.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$779.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$770.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$733.60
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$733.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$733.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$733.60
|
| Rate for Payer: Multiplan Commercial |
$852.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$779.45
|
| Rate for Payer: United Healthcare Commercial |
$871.15
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
OP
|
$917.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
9602357001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$406.14 |
| Max. Negotiated Rate |
$871.15 |
| Rate for Payer: Aetna of VT Commercial |
$871.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$821.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$406.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$821.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$552.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$779.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$742.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$412.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$729.01
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$733.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$733.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$733.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$412.65
|
| Rate for Payer: Multiplan Commercial |
$852.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$779.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$412.65
|
| Rate for Payer: United Healthcare Commercial |
$871.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$412.65
|
| Rate for Payer: United Healthcare VA CCN |
$412.65
|
|
|
CLTX SCAPULAR FX W/O MNPJ
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 23570
|
| Hospital Charge Code |
5102357001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna of VT Commercial |
$288.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$134.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$183.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$246.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.68
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$243.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$136.80
|
| Rate for Payer: Multiplan Commercial |
$282.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$136.80
|
| Rate for Payer: United Healthcare Commercial |
$288.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$136.80
|
| Rate for Payer: United Healthcare VA CCN |
$136.80
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Professional
|
Both
|
$1,824.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9602366501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$389.89 |
| Max. Negotiated Rate |
$1,714.56 |
| Rate for Payer: Aetna of VT Commercial |
$1,714.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,634.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$401.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,634.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$545.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$448.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$720.17
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cigna Commercial |
$738.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$426.18
|
| Rate for Payer: Multiplan Commercial |
$1,696.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$553.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare Commercial |
$599.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare VA CCN |
$389.89
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9822366501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$389.89 |
| Max. Negotiated Rate |
$738.36 |
| Rate for Payer: Aetna of VT Commercial |
$603.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$401.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$545.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$448.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$720.17
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$738.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$426.18
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$553.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare Commercial |
$599.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare VA CCN |
$389.89
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
OP
|
$1,824.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9602366501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$807.85 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,732.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,634.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$807.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,634.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,098.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,550.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,477.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$820.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,450.08
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cigna Commercial |
$1,459.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,459.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,459.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$820.80
|
| Rate for Payer: Multiplan Commercial |
$1,696.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,550.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$820.80
|
| Rate for Payer: United Healthcare Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$820.80
|
| Rate for Payer: United Healthcare VA CCN |
$820.80
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9822366501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$539.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$513.60
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9602366502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$389.89 |
| Max. Negotiated Rate |
$738.36 |
| Rate for Payer: Aetna of VT Commercial |
$603.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$401.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$545.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$720.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$448.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$720.17
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$738.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$426.18
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$553.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare Commercial |
$599.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$389.89
|
| Rate for Payer: United Healthcare VA CCN |
$389.89
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
IP
|
$1,182.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
5102366501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$874.80 |
| Max. Negotiated Rate |
$1,122.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,122.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$874.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$874.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,004.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$992.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$945.60
|
| Rate for Payer: Cash Price |
$591.00
|
| Rate for Payer: Cigna Commercial |
$945.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$945.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$945.60
|
| Rate for Payer: Multiplan Commercial |
$1,099.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,004.70
|
| Rate for Payer: United Healthcare Commercial |
$1,122.90
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9602366502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$539.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$513.60
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9822366501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$284.34 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$284.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$386.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$520.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$288.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$510.39
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$288.90
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare VA CCN |
$288.90
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
IP
|
$1,824.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
9602366501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,349.94 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,732.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,349.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,349.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,550.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,532.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,459.20
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cigna Commercial |
$1,459.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,459.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,459.20
|
| Rate for Payer: Multiplan Commercial |
$1,696.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,550.40
|
| Rate for Payer: United Healthcare Commercial |
$1,732.80
|
|
|
CLTX SHO DSLC FX GR HMRL TBR
|
Facility
|
OP
|
$1,182.00
|
|
|
Service Code
|
CPT 23665
|
| Hospital Charge Code |
5102366501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$523.51 |
| Max. Negotiated Rate |
$1,122.90 |
| Rate for Payer: Aetna of VT Commercial |
$1,122.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,058.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$523.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,058.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$711.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,004.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$957.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$531.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$939.69
|
| Rate for Payer: Cash Price |
$591.00
|
| Rate for Payer: Cigna Commercial |
$945.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$945.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$945.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$531.90
|
| Rate for Payer: Multiplan Commercial |
$1,099.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,004.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$531.90
|
| Rate for Payer: United Healthcare Commercial |
$1,122.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$531.90
|
| Rate for Payer: United Healthcare VA CCN |
$531.90
|
|
