|
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
|
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 W/MNPJ W/ANES
|
Professional
|
Both
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9822365501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$393.78 |
| Max. Negotiated Rate |
$898.64 |
| Rate for Payer: Aetna of VT Commercial |
$898.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$405.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$551.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$452.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.24
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$746.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$652.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$652.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$393.78
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare Commercial |
$605.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare VA CCN |
$393.78
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
IP
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9822365501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$707.54 |
| Max. Negotiated Rate |
$908.20 |
| Rate for Payer: Aetna of VT Commercial |
$908.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$707.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$707.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$803.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$764.80
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$764.80
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$812.60
|
| Rate for Payer: United Healthcare Commercial |
$908.20
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Professional
|
Both
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$393.78 |
| Max. Negotiated Rate |
$898.64 |
| Rate for Payer: Aetna of VT Commercial |
$898.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$405.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$551.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$452.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.24
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$746.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$652.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$652.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$393.78
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare Commercial |
$605.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare VA CCN |
$393.78
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Professional
|
Both
|
$1,909.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
5102365501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$393.78 |
| Max. Negotiated Rate |
$1,794.46 |
| Rate for Payer: Aetna of VT Commercial |
$1,794.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,710.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$405.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,710.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$551.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$452.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.24
|
| Rate for Payer: Cash Price |
$954.50
|
| Rate for Payer: Cash Price |
$954.50
|
| Rate for Payer: Cigna Commercial |
$746.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$652.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$652.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$393.78
|
| Rate for Payer: Multiplan Commercial |
$1,775.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare Commercial |
$605.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare VA CCN |
$393.78
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Professional
|
Both
|
$2,865.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$393.78 |
| Max. Negotiated Rate |
$2,693.10 |
| Rate for Payer: Aetna of VT Commercial |
$2,693.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,566.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$405.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,566.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$551.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$531.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$452.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.24
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cigna Commercial |
$746.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$652.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$652.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$393.78
|
| Rate for Payer: Multiplan Commercial |
$2,664.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare Commercial |
$605.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$393.78
|
| Rate for Payer: United Healthcare VA CCN |
$393.78
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
IP
|
$2,865.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,120.39 |
| Max. Negotiated Rate |
$2,721.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,721.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,120.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,120.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,435.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,406.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,292.00
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cigna Commercial |
$2,292.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,292.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,292.00
|
| Rate for Payer: Multiplan Commercial |
$2,664.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,435.25
|
| Rate for Payer: United Healthcare Commercial |
$2,721.75
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
OP
|
$2,865.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,268.91 |
| Max. Negotiated Rate |
$2,721.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,721.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,566.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,268.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,566.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,724.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,435.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,320.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,289.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,277.68
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cigna Commercial |
$2,292.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,292.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,292.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,289.25
|
| Rate for Payer: Multiplan Commercial |
$2,664.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,435.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,289.25
|
| Rate for Payer: United Healthcare Commercial |
$2,721.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,289.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,289.25
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
IP
|
$1,909.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
5102365501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,412.85 |
| Max. Negotiated Rate |
$1,813.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,813.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,412.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,412.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,622.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,603.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,527.20
|
| Rate for Payer: Cash Price |
$954.50
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,527.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,527.20
|
| Rate for Payer: Multiplan Commercial |
$1,775.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,622.65
|
| Rate for Payer: United Healthcare Commercial |
$1,813.55
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$423.41 |
| Max. Negotiated Rate |
$908.20 |
| Rate for Payer: Aetna of VT Commercial |
$908.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$575.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$774.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$430.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$760.02
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$764.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$430.20
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$812.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$430.20
|
| Rate for Payer: United Healthcare Commercial |
$908.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$430.20
|
| Rate for Payer: United Healthcare VA CCN |
$430.20
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
IP
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9602365502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$707.54 |
| Max. Negotiated Rate |
$908.20 |
| Rate for Payer: Aetna of VT Commercial |
$908.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$707.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$707.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$803.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$764.80
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$764.80
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$812.60
|
| Rate for Payer: United Healthcare Commercial |
$908.20
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
OP
|
$1,909.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
5102365501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$845.50 |
| Max. Negotiated Rate |
$1,813.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,813.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,710.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$845.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,710.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,149.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,622.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,546.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$859.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,517.65
|
| Rate for Payer: Cash Price |
$954.50
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,527.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,527.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$859.05
|
| Rate for Payer: Multiplan Commercial |
$1,775.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,622.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$859.05
|
| Rate for Payer: United Healthcare Commercial |
$1,813.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$859.05
|
| Rate for Payer: United Healthcare VA CCN |
$859.05
|
|
|
CLTX SHO DSLC W/MNPJ W/ANES
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
CPT 23655
|
| Hospital Charge Code |
9822365501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$423.41 |
| Max. Negotiated Rate |
$908.20 |
| Rate for Payer: Aetna of VT Commercial |
$908.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$856.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$575.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$812.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$774.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$430.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$760.02
|
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Cigna Commercial |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$764.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$764.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$430.20
|
| Rate for Payer: Multiplan Commercial |
$889.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$812.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$430.20
|
| Rate for Payer: United Healthcare Commercial |
$908.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$430.20
|
| Rate for Payer: United Healthcare VA CCN |
$430.20
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
OP
|
$1,364.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$604.12 |
| Max. Negotiated Rate |
$1,295.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,295.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,222.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$604.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,222.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$821.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,159.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,104.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$613.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,084.38
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cigna Commercial |
$1,091.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,091.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,091.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$613.80
|
| Rate for Payer: Multiplan Commercial |
$1,268.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,159.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$613.80
|
| Rate for Payer: United Healthcare Commercial |
$1,295.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$613.80
|
| Rate for Payer: United Healthcare VA CCN |
$613.80
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
OP
|
$501.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
5102365001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$221.89 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Aetna of VT Commercial |
$475.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$448.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$221.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$448.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$301.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$405.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$225.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$398.30
|
| Rate for Payer: Cash Price |
$250.50
|
| Rate for Payer: Cigna Commercial |
$400.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$225.45
|
| Rate for Payer: Multiplan Commercial |
$465.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$225.45
|
| Rate for Payer: United Healthcare Commercial |
$475.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.45
|
| Rate for Payer: United Healthcare VA CCN |
$225.45
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
IP
|
$1,364.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,009.50 |
| Max. Negotiated Rate |
$1,295.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,295.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,009.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,009.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,159.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,145.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,091.20
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cigna Commercial |
$1,091.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,091.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,091.20
|
| Rate for Payer: Multiplan Commercial |
$1,268.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,159.40
|
| Rate for Payer: United Healthcare Commercial |
$1,295.80
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$382.67 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Aetna of VT Commercial |
$820.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$774.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$382.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$774.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$520.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$734.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$699.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$388.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$686.88
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$691.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$691.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$691.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$388.80
|
| Rate for Payer: Multiplan Commercial |
$803.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$734.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$388.80
|
| Rate for Payer: United Healthcare Commercial |
$820.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$388.80
|
| Rate for Payer: United Healthcare VA CCN |
$388.80
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
IP
|
$501.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
5102365001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$370.79 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Aetna of VT Commercial |
$475.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$420.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$400.80
|
| Rate for Payer: Cash Price |
$250.50
|
| Rate for Payer: Cigna Commercial |
$400.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.80
|
| Rate for Payer: Multiplan Commercial |
$465.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.85
|
| Rate for Payer: United Healthcare Commercial |
$475.95
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Professional
|
Both
|
$1,364.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$295.20 |
| Max. Negotiated Rate |
$1,282.16 |
| Rate for Payer: Aetna of VT Commercial |
$1,282.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,222.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$304.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,222.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$339.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$441.70
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cash Price |
$682.00
|
| Rate for Payer: Cigna Commercial |
$557.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$542.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$542.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$328.61
|
| Rate for Payer: Multiplan Commercial |
$1,268.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$419.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare Commercial |
$454.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare VA CCN |
$295.20
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$639.45 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Aetna of VT Commercial |
$820.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$639.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$639.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$734.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$725.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$691.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$691.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$691.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$691.20
|
| Rate for Payer: Multiplan Commercial |
$803.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$734.40
|
| Rate for Payer: United Healthcare Commercial |
$820.80
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Professional
|
Both
|
$501.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
5102365001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$295.20 |
| Max. Negotiated Rate |
$557.09 |
| Rate for Payer: Aetna of VT Commercial |
$470.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$448.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$304.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$448.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$339.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$441.70
|
| Rate for Payer: Cash Price |
$250.50
|
| Rate for Payer: Cash Price |
$250.50
|
| Rate for Payer: Cigna Commercial |
$557.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$542.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$542.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$328.61
|
| Rate for Payer: Multiplan Commercial |
$465.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$419.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare Commercial |
$454.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare VA CCN |
$295.20
|
|
|
CLTX SHO DSLC W/MNPJ WO ANES
|
Professional
|
Both
|
$864.00
|
|
|
Service Code
|
CPT 23650
|
| Hospital Charge Code |
9602365002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$295.20 |
| Max. Negotiated Rate |
$812.16 |
| Rate for Payer: Aetna of VT Commercial |
$812.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$774.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$304.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$774.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$441.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$339.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$441.70
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$557.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$542.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$542.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$328.61
|
| Rate for Payer: Multiplan Commercial |
$803.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$419.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare Commercial |
$454.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$295.20
|
| Rate for Payer: United Healthcare VA CCN |
$295.20
|
|
|
CLTX TIBIAL SHAFT FX W/O MANIP
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 27750
|
| Hospital Charge Code |
9812775002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$317.76 |
| Max. Negotiated Rate |
$601.75 |
| Rate for Payer: Aetna of VT Commercial |
$477.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$455.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$327.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$455.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$444.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$491.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$491.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$365.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$491.52
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cigna Commercial |
$601.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$564.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$564.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$343.45
|
| Rate for Payer: Multiplan Commercial |
$472.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$451.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$317.76
|
| Rate for Payer: United Healthcare Commercial |
$488.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$317.76
|
| Rate for Payer: United Healthcare VA CCN |
$317.76
|
|
|
CLTX TIBIAL SHAFT FX W/O MANIP
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
CPT 27750
|
| Hospital Charge Code |
9602775002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$224.99 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna of VT Commercial |
$482.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$455.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$224.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$455.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$305.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$431.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$411.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$228.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$403.86
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cigna Commercial |
$406.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$406.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$406.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$472.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$431.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$228.60
|
| Rate for Payer: United Healthcare Commercial |
$482.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$228.60
|
| Rate for Payer: United Healthcare VA CCN |
$228.60
|
|
