|
EXC F/E/E/N/L MAL+MRG 1.1-2
|
Professional
|
Both
|
$361.00
|
|
|
Service Code
|
CPT 11642
|
| Hospital Charge Code |
9821164201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$171.54 |
| Max. Negotiated Rate |
$414.01 |
| Rate for Payer: Aetna of VT Commercial |
$339.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$323.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$176.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$323.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$240.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$375.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$375.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$197.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$375.67
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$192.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$414.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$414.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$254.09
|
| Rate for Payer: Multiplan Commercial |
$335.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$243.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$171.54
|
| Rate for Payer: United Healthcare Commercial |
$263.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.54
|
| Rate for Payer: United Healthcare VA CCN |
$171.54
|
|
|
EXC F/E/E/N/L MAL+MRG 1.1-2
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 11642
|
| Hospital Charge Code |
9601164202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$451.46 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna of VT Commercial |
$579.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$451.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$451.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$518.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$512.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$488.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.00
|
| Rate for Payer: Multiplan Commercial |
$567.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$518.50
|
| Rate for Payer: United Healthcare Commercial |
$579.50
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
IP
|
$505.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$373.75 |
| Max. Negotiated Rate |
$479.75 |
| Rate for Payer: Aetna of VT Commercial |
$479.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$373.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$373.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$429.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$424.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$404.00
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$404.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$404.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$404.00
|
| Rate for Payer: Multiplan Commercial |
$469.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$429.25
|
| Rate for Payer: United Healthcare Commercial |
$479.75
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
OP
|
$505.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$223.66 |
| Max. Negotiated Rate |
$479.75 |
| Rate for Payer: Aetna of VT Commercial |
$479.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$223.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$304.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$429.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$409.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$227.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$401.48
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$404.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$404.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$404.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$227.25
|
| Rate for Payer: Multiplan Commercial |
$469.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$429.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$227.25
|
| Rate for Payer: United Healthcare Commercial |
$479.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.25
|
| Rate for Payer: United Healthcare VA CCN |
$227.25
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Professional
|
Both
|
$505.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$213.74 |
| Max. Negotiated Rate |
$488.07 |
| Rate for Payer: Aetna of VT Commercial |
$474.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$299.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$245.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$425.40
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$239.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$298.22
|
| Rate for Payer: Multiplan Commercial |
$469.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$303.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare Commercial |
$328.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare VA CCN |
$213.74
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Professional
|
Both
|
$648.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
5101164301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$213.74 |
| Max. Negotiated Rate |
$609.12 |
| Rate for Payer: Aetna of VT Commercial |
$609.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$299.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$245.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$425.40
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial |
$239.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$298.22
|
| Rate for Payer: Multiplan Commercial |
$602.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$303.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare Commercial |
$328.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare VA CCN |
$213.74
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
OP
|
$648.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
5101164301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$287.00 |
| Max. Negotiated Rate |
$615.60 |
| Rate for Payer: Aetna of VT Commercial |
$615.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$287.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$580.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$390.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$550.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$524.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$291.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$515.16
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial |
$518.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$518.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$518.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$291.60
|
| Rate for Payer: Multiplan Commercial |
$602.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$550.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$291.60
|
| Rate for Payer: United Healthcare Commercial |
$615.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$291.60
|
| Rate for Payer: United Healthcare VA CCN |
$291.60
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
IP
|
$648.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
5101164301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$479.58 |
| Max. Negotiated Rate |
$615.60 |
| Rate for Payer: Aetna of VT Commercial |
$615.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$479.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$479.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$550.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$544.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$518.40
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial |
$518.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$518.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$518.40
|
| Rate for Payer: Multiplan Commercial |
$602.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$550.80
|
| Rate for Payer: United Healthcare Commercial |
$615.60
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
OP
|
$1,152.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$510.22 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna of VT Commercial |
$1,094.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,032.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$510.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,032.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$693.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$979.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$933.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$518.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$915.84
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$921.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$921.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$921.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$518.40
|
| Rate for Payer: Multiplan Commercial |
$1,071.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$979.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$518.40
|
| Rate for Payer: United Healthcare Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$518.40
|
| Rate for Payer: United Healthcare VA CCN |
$518.40
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Facility
|
IP
|
$1,152.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$852.60 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna of VT Commercial |
$1,094.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$852.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$852.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$979.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$967.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$921.60
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$921.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$921.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$921.60
|
| Rate for Payer: Multiplan Commercial |
$1,071.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$979.20
|
| Rate for Payer: United Healthcare Commercial |
$1,094.40
|
|
|
EXC F/E/E/N/L MAL+MRG 2.1-3
|
Professional
|
Both
|
$1,152.00
|
|
|
Service Code
|
CPT 11643
|
| Hospital Charge Code |
9601164301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$213.74 |
| Max. Negotiated Rate |
$1,082.88 |
| Rate for Payer: Aetna of VT Commercial |
$1,082.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,032.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,032.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$299.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$425.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$245.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$425.40
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$239.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$298.22
|
| Rate for Payer: Multiplan Commercial |
$1,071.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$303.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare Commercial |
$328.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.74
|
| Rate for Payer: United Healthcare VA CCN |
$213.74
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Professional
|
Both
|
$751.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
5101164401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$263.36 |
| Max. Negotiated Rate |
$705.94 |
| Rate for Payer: Aetna of VT Commercial |
$705.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$672.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$271.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$672.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$368.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$302.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$538.25
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$296.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$601.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$601.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$366.79
|
| Rate for Payer: Multiplan Commercial |
$698.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare Commercial |
$405.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare VA CCN |
$263.36
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
OP
|
$751.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
5101164401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$332.62 |
| Max. Negotiated Rate |
$713.45 |
| Rate for Payer: Aetna of VT Commercial |
$713.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$672.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$332.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$672.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$452.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$638.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$608.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$337.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$597.04
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$600.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$600.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$600.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$337.95
|
| Rate for Payer: Multiplan Commercial |
$698.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$638.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$337.95
|
| Rate for Payer: United Healthcare Commercial |
$713.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$337.95
|
| Rate for Payer: United Healthcare VA CCN |
$337.95
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
IP
|
$751.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
5101164401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$555.82 |
| Max. Negotiated Rate |
$713.45 |
| Rate for Payer: Aetna of VT Commercial |
$713.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$555.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$555.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$638.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$630.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$600.80
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$600.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$600.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$600.80
|
| Rate for Payer: Multiplan Commercial |
$698.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$638.35
|
| Rate for Payer: United Healthcare Commercial |
$713.45
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
OP
|
$938.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$415.44 |
| Max. Negotiated Rate |
$891.10 |
| Rate for Payer: Aetna of VT Commercial |
$891.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$840.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$415.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$840.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$564.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$797.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$759.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$422.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$745.71
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cigna Commercial |
$750.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$750.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$750.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$422.10
|
| Rate for Payer: Multiplan Commercial |
$872.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$797.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$422.10
|
| Rate for Payer: United Healthcare Commercial |
$891.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$422.10
|
| Rate for Payer: United Healthcare VA CCN |
$422.10
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
OP
|
$1,689.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$748.06 |
| Max. Negotiated Rate |
$1,604.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,604.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,513.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$748.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,513.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,016.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,435.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,368.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$760.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,342.76
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$1,351.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,351.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,351.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$760.05
|
| Rate for Payer: Multiplan Commercial |
$1,570.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,435.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$760.05
|
| Rate for Payer: United Healthcare Commercial |
$1,604.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$760.05
|
| Rate for Payer: United Healthcare VA CCN |
$760.05
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Professional
|
Both
|
$938.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$263.36 |
| Max. Negotiated Rate |
$881.72 |
| Rate for Payer: Aetna of VT Commercial |
$881.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$840.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$271.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$840.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$368.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$302.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$538.25
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cigna Commercial |
$296.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$601.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$601.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$366.79
|
| Rate for Payer: Multiplan Commercial |
$872.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare Commercial |
$405.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare VA CCN |
$263.36
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
IP
|
$1,689.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,250.03 |
| Max. Negotiated Rate |
$1,604.55 |
| Rate for Payer: Aetna of VT Commercial |
$1,604.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,250.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,250.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,435.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,418.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,351.20
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$1,351.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,351.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,351.20
|
| Rate for Payer: Multiplan Commercial |
$1,570.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,435.65
|
| Rate for Payer: United Healthcare Commercial |
$1,604.55
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Professional
|
Both
|
$1,689.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$263.36 |
| Max. Negotiated Rate |
$1,587.66 |
| Rate for Payer: Aetna of VT Commercial |
$1,587.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,513.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$271.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,513.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$368.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$538.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$302.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$538.25
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$296.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$601.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$601.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$366.79
|
| Rate for Payer: Multiplan Commercial |
$1,570.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare Commercial |
$405.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$263.36
|
| Rate for Payer: United Healthcare VA CCN |
$263.36
|
|
|
EXC F/E/E/N/L MAL+MRG 3.1-4
|
Facility
|
IP
|
$938.00
|
|
|
Service Code
|
CPT 11644
|
| Hospital Charge Code |
9601164402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$694.21 |
| Max. Negotiated Rate |
$891.10 |
| Rate for Payer: Aetna of VT Commercial |
$891.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$694.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$694.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$797.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$787.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$750.40
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cigna Commercial |
$750.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$750.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$750.40
|
| Rate for Payer: Multiplan Commercial |
$872.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$797.30
|
| Rate for Payer: United Healthcare Commercial |
$891.10
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Professional
|
Both
|
$2,923.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
5101164601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$361.05 |
| Max. Negotiated Rate |
$2,747.62 |
| Rate for Payer: Aetna of VT Commercial |
$2,747.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,618.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$371.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,618.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$415.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$727.25
|
| Rate for Payer: Cash Price |
$1,461.50
|
| Rate for Payer: Cash Price |
$1,461.50
|
| Rate for Payer: Cigna Commercial |
$406.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$473.79
|
| Rate for Payer: Multiplan Commercial |
$2,718.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare Commercial |
$555.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare VA CCN |
$361.05
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Facility
|
IP
|
$4,209.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$3,115.08 |
| Max. Negotiated Rate |
$3,998.55 |
| Rate for Payer: Aetna of VT Commercial |
$3,998.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,115.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,115.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,577.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,535.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,367.20
|
| Rate for Payer: Cash Price |
$2,104.50
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,367.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,367.20
|
| Rate for Payer: Multiplan Commercial |
$3,914.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,577.65
|
| Rate for Payer: United Healthcare Commercial |
$3,998.55
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Facility
|
OP
|
$2,923.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
5101164601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,294.60 |
| Max. Negotiated Rate |
$2,776.85 |
| Rate for Payer: Aetna of VT Commercial |
$2,776.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,618.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,294.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,618.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,759.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,484.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,367.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,315.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,323.78
|
| Rate for Payer: Cash Price |
$1,461.50
|
| Rate for Payer: Cigna Commercial |
$2,338.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,338.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,338.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,315.35
|
| Rate for Payer: Multiplan Commercial |
$2,718.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,484.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,315.35
|
| Rate for Payer: United Healthcare Commercial |
$2,776.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,315.35
|
| Rate for Payer: United Healthcare VA CCN |
$1,315.35
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Professional
|
Both
|
$1,286.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
9601164602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$361.05 |
| Max. Negotiated Rate |
$1,208.84 |
| Rate for Payer: Aetna of VT Commercial |
$1,208.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,152.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$371.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,152.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$727.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$415.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$727.25
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$406.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$780.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$780.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$473.79
|
| Rate for Payer: Multiplan Commercial |
$1,195.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$512.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare Commercial |
$555.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$361.05
|
| Rate for Payer: United Healthcare VA CCN |
$361.05
|
|
|
EXC F/E/E/N/L MAL+MRG >4 CM
|
Facility
|
IP
|
$2,923.00
|
|
|
Service Code
|
CPT 11646
|
| Hospital Charge Code |
5101164601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,163.31 |
| Max. Negotiated Rate |
$2,776.85 |
| Rate for Payer: Aetna of VT Commercial |
$2,776.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,163.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,163.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,484.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,455.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,338.40
|
| Rate for Payer: Cash Price |
$1,461.50
|
| Rate for Payer: Cigna Commercial |
$2,338.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,338.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,338.40
|
| Rate for Payer: Multiplan Commercial |
$2,718.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,484.55
|
| Rate for Payer: United Healthcare Commercial |
$2,776.85
|
|
