|
EXC TR-EXT B9+MARG 1.1-2 CM
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
9601140202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$110.30 |
| Max. Negotiated Rate |
$394.80 |
| Rate for Payer: Aetna of VT Commercial |
$394.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$376.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$113.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$376.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$154.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$231.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$231.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$126.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$231.49
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$123.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$163.30
|
| Rate for Payer: Multiplan Commercial |
$390.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$156.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$110.30
|
| Rate for Payer: United Healthcare Commercial |
$169.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.30
|
| Rate for Payer: United Healthcare VA CCN |
$110.30
|
|
|
EXC TR-EXT B9+MARG 1.1-2 CM
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
9821140201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$310.84 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: Aetna of VT Commercial |
$399.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$352.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$336.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$336.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$336.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$336.00
|
| Rate for Payer: Multiplan Commercial |
$390.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$357.00
|
| Rate for Payer: United Healthcare Commercial |
$399.00
|
|
|
EXC TR-EXT B9+MARG 1.1-2 CM
|
Facility
|
IP
|
$373.27
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
4501140201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$276.26 |
| Max. Negotiated Rate |
$354.61 |
| Rate for Payer: Aetna of VT Commercial |
$354.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$276.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$276.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$313.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$298.62
|
| Rate for Payer: Cash Price |
$186.64
|
| Rate for Payer: Cigna Commercial |
$298.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$298.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$298.62
|
| Rate for Payer: Multiplan Commercial |
$347.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.28
|
| Rate for Payer: United Healthcare Commercial |
$354.61
|
|
|
EXC TR-EXT B9+MARG 1.1-2 CM
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
9821140201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$186.02 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: Aetna of VT Commercial |
$399.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$376.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$186.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$376.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$252.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$357.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$340.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$189.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$333.90
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$336.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$336.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$336.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$390.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$357.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$399.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$189.00
|
| Rate for Payer: United Healthcare VA CCN |
$189.00
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$364.13 |
| Max. Negotiated Rate |
$467.40 |
| Rate for Payer: Aetna of VT Commercial |
$467.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$364.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$418.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$393.60
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.60
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$418.20
|
| Rate for Payer: United Healthcare Commercial |
$467.40
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
5101140301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$276.80 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Aetna of VT Commercial |
$355.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$276.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$276.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$314.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$299.20
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$299.20
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.90
|
| Rate for Payer: United Healthcare Commercial |
$355.30
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
5101140301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$351.56 |
| Rate for Payer: Aetna of VT Commercial |
$351.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$164.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.56
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$160.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.87
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare Commercial |
$219.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare VA CCN |
$142.90
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
5101140301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.64 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Aetna of VT Commercial |
$355.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$165.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$335.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$225.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$302.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$168.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$297.33
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$299.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$299.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$168.30
|
| Rate for Payer: Multiplan Commercial |
$347.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$168.30
|
| Rate for Payer: United Healthcare Commercial |
$355.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.30
|
| Rate for Payer: United Healthcare VA CCN |
$168.30
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$217.91 |
| Max. Negotiated Rate |
$467.40 |
| Rate for Payer: Aetna of VT Commercial |
$467.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$217.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$296.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$418.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$398.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$221.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.14
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$221.40
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$418.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$221.40
|
| Rate for Payer: United Healthcare Commercial |
$467.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.40
|
| Rate for Payer: United Healthcare VA CCN |
$221.40
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Professional
|
Both
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$462.48 |
| Rate for Payer: Aetna of VT Commercial |
$462.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$164.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.56
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$160.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.87
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare Commercial |
$219.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare VA CCN |
$142.90
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
OP
|
$865.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$383.11 |
| Max. Negotiated Rate |
$821.75 |
| Rate for Payer: Aetna of VT Commercial |
$821.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$774.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$383.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$774.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$520.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$735.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$700.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$389.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$687.67
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cigna Commercial |
$692.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$692.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$692.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$389.25
|
| Rate for Payer: Multiplan Commercial |
$804.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$735.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$389.25
|
| Rate for Payer: United Healthcare Commercial |
$821.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$389.25
|
| Rate for Payer: United Healthcare VA CCN |
$389.25
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
IP
|
$865.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$640.19 |
| Max. Negotiated Rate |
$821.75 |
| Rate for Payer: Aetna of VT Commercial |
$821.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$640.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$640.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$735.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$726.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$692.00
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cigna Commercial |
$692.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$692.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$692.00
|
| Rate for Payer: Multiplan Commercial |
$804.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$735.25
|
| Rate for Payer: United Healthcare Commercial |
$821.75
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9821140301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$364.13 |
| Max. Negotiated Rate |
$467.40 |
| Rate for Payer: Aetna of VT Commercial |
$467.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$364.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$418.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$393.60
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.60
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$418.20
|
| Rate for Payer: United Healthcare Commercial |
$467.40
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Professional
|
Both
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9821140301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$462.48 |
| Rate for Payer: Aetna of VT Commercial |
$462.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$164.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.56
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$160.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.87
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare Commercial |
$219.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare VA CCN |
$142.90
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9821140301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$217.91 |
| Max. Negotiated Rate |
$467.40 |
| Rate for Payer: Aetna of VT Commercial |
$467.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$217.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$440.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$296.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$418.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$398.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$221.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$391.14
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$221.40
|
| Rate for Payer: Multiplan Commercial |
$457.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$418.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$221.40
|
| Rate for Payer: United Healthcare Commercial |
$467.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.40
|
| Rate for Payer: United Healthcare VA CCN |
$221.40
|
|
|
EXC TR-EXT B9+MARG 2.1-3CM
|
Professional
|
Both
|
$865.00
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
9601140301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$813.10 |
| Rate for Payer: Aetna of VT Commercial |
$813.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$774.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$774.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$164.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.56
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cigna Commercial |
$160.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.87
|
| Rate for Payer: Multiplan Commercial |
$804.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare Commercial |
$219.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.90
|
| Rate for Payer: United Healthcare VA CCN |
$142.90
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Professional
|
Both
|
$627.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
5101140401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$589.38 |
| Rate for Payer: Aetna of VT Commercial |
$589.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$561.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$161.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$561.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$219.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$301.50
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna Commercial |
$175.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$583.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$222.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare Commercial |
$240.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare VA CCN |
$156.51
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$1,144.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$846.67 |
| Max. Negotiated Rate |
$1,086.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,086.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$846.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$846.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$972.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$960.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$915.20
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cigna Commercial |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$915.20
|
| Rate for Payer: Multiplan Commercial |
$1,063.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$972.40
|
| Rate for Payer: United Healthcare Commercial |
$1,086.80
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$627.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
5101140401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$464.04 |
| Max. Negotiated Rate |
$595.65 |
| Rate for Payer: Aetna of VT Commercial |
$595.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$464.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$464.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$526.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$501.60
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna Commercial |
$501.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$501.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$501.60
|
| Rate for Payer: Multiplan Commercial |
$583.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$532.95
|
| Rate for Payer: United Healthcare Commercial |
$595.65
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$627.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
5101140401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$277.70 |
| Max. Negotiated Rate |
$595.65 |
| Rate for Payer: Aetna of VT Commercial |
$595.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$561.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$277.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$561.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$377.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$507.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$282.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$498.46
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna Commercial |
$501.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$501.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$501.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$282.15
|
| Rate for Payer: Multiplan Commercial |
$583.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$532.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$282.15
|
| Rate for Payer: United Healthcare Commercial |
$595.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$282.15
|
| Rate for Payer: United Healthcare VA CCN |
$282.15
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$228.98 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna of VT Commercial |
$491.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$463.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$228.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$463.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$311.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$439.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$418.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.01
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$413.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$232.65
|
| Rate for Payer: Multiplan Commercial |
$480.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$439.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$232.65
|
| Rate for Payer: United Healthcare Commercial |
$491.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$232.65
|
| Rate for Payer: United Healthcare VA CCN |
$232.65
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$382.63 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna of VT Commercial |
$491.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$382.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$382.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$439.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$434.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$413.60
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$413.60
|
| Rate for Payer: Multiplan Commercial |
$480.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$439.45
|
| Rate for Payer: United Healthcare Commercial |
$491.15
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Professional
|
Both
|
$1,144.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$1,075.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,075.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$161.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$219.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$301.50
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cigna Commercial |
$175.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$1,063.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$222.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare Commercial |
$240.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare VA CCN |
$156.51
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Professional
|
Both
|
$517.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$485.98 |
| Rate for Payer: Aetna of VT Commercial |
$485.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$463.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$161.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$463.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$219.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$301.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$301.50
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$175.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$480.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$222.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare Commercial |
$240.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.51
|
| Rate for Payer: United Healthcare VA CCN |
$156.51
|
|
|
EXC TR-EXT B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$1,144.00
|
|
|
Service Code
|
CPT 11404
|
| Hospital Charge Code |
9601140401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$506.68 |
| Max. Negotiated Rate |
$1,086.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,086.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$506.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$688.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$972.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$926.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$514.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$909.48
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cigna Commercial |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$915.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$514.80
|
| Rate for Payer: Multiplan Commercial |
$1,063.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$972.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$514.80
|
| Rate for Payer: United Healthcare Commercial |
$1,086.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$514.80
|
| Rate for Payer: United Healthcare VA CCN |
$514.80
|
|
