Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
Waiver service, nos
Low
$1
Average
$13
Median
$17
High
$20
Each hospital's average Aetna rate, under the methodology and billing class chosen below.
20 hospitals; the 90th percentile is 5.4× the 10th. Each bar is a price range and its height is how many hospitals fall in it. Hover a bar, or a row in the ladder, for details.
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22 hospital rates
iThe hospitals that file a Aetna rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.| # | Plans | |||||||
|---|---|---|---|---|---|---|---|---|
| 1 | Acadia Hospital Bangor, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 2 | Alta Newport Hospital, LLC Tustin, CA facility · case rate · outpatient | 2 | $9 | $9 | — | — | — | $9 – $9 |
| 3 | Blue Hill Memorial Hospital Hill, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 4 | Charles A. Dean Memorial Hospital Greenville, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 5 | Cheshire Medical Center Keene, NH professional · fee schedule · outpatient | 2 | $3 | $3 | — | — | — | $3 – $3 |
| 6 | Covenant Medical Center Lubbock, TX fee schedule · outpatient | 1 | $18 | $18 | — | — | — | $18 – $18 |
| 7 | ERIE COUNTY MEDICAL CENTER CORPORATION Buffalo, NY fee schedule · outpatient | 1 | $3 | $3 | — | — | — | $3 – $3 |
| 8 | Eastern Maine Medical Center Bangor, ME facility · case rate · outpatient | 1 | $18 | $18 | — | — | — | $18 – $18 |
| 9 | Eastern Maine Medical Center Bangor, ME professional · fee schedule · outpatient | 2 | $17 | $17 | — | — | — | $17 – $17 |
| 10 | Garnet Health Medical Center Middletown, NY facility · fee schedule · outpatient | 1 | $20 | $20 | — | — | — | $20 – $20 |
| 11 | Garnet Health Medical Center Catskills Harris, NY facility · fee schedule · outpatient | 1 | $18 | $18 | — | — | — | $18 – $18 |
| 12 | Granville Medical Center Oxford, NC facility · percent of total billed charges · inpatientfrom % of charges | 1 | $1 | $1 | — | — | — | $1 – $1 |
| 13 | Granville Medical Center Oxford, NC facility · percent of total billed charges · outpatientfrom % of charges | 1 | $1 | $1 | — | — | — | $1 – $1 |
| 14 | Lubbock Heritage Hospital LLC Lubbock, TX fee schedule · outpatient | 1 | $18 | $18 | — | — | — | $18 – $18 |
| 15 | Maine Coast Regional Health Facilities Ellsworth, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 16 | Mary Hitchcock Memorial Hospital Lebanon, NH professional · fee schedule · outpatient | 1 | $3 | $3 | — | — | — | $3 – $3 |
| 17 | Mayo Regional Hospital Dover Foxcroft, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 18 | Mercy Hospital Portland, ME professional · fee schedule · outpatient | 2 | $17 | $17 | — | — | — | $17 – $17 |
| 19 | Sarasota Memorial Hospital Sarasota, FL fee schedule · outpatient | 2 | $4 | $4 | $0 | 6% | — | $3 – $4 |
| 20 | Sebasticook Valley Health Pittsfield, ME professional · fee schedule · outpatient | 1 | $17 | $17 | — | — | — | $17 – $17 |
| 21 | The Aroostook Medical Center Isle, ME professional · fee schedule · outpatient | 2 | $17 | $17 | — | — | — | $17 – $17 |
| 22 | The New London Hospital Association, Inc. London, NH professional · fee schedule · outpatient | 1 | $3 | $3 | — | — | — | $3 – $3 |
← Payers reporting HCPCS T2025 · Snapshot 20261113T090226Z-3ce6c0b8