|
EXC TR-EXT MAL+MARG 2.1-3 CM
|
Professional
|
Both
|
$648.00
|
|
|
Service Code
|
CPT 11603
|
| Hospital Charge Code |
5101160301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$182.35 |
| 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 |
$187.82
|
| 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 |
$255.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$337.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$337.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$209.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$337.80
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial |
$204.61
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$430.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$430.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$264.58
|
| Rate for Payer: Multiplan Commercial |
$602.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$182.35
|
| Rate for Payer: United Healthcare Commercial |
$280.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.35
|
| Rate for Payer: United Healthcare VA CCN |
$182.35
|
|
|
EXC TR-EXT MAL+MARG 2.1-3 CM
|
Facility
|
IP
|
$839.00
|
|
|
Service Code
|
CPT 11603
|
| Hospital Charge Code |
9601160302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$620.94 |
| Max. Negotiated Rate |
$797.05 |
| Rate for Payer: Aetna of VT Commercial |
$797.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$620.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$620.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$713.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$704.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$671.20
|
| Rate for Payer: Cash Price |
$419.50
|
| Rate for Payer: Cigna Commercial |
$671.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$671.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$671.20
|
| Rate for Payer: Multiplan Commercial |
$780.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$713.15
|
| Rate for Payer: United Healthcare Commercial |
$797.05
|
|
|
EXC TR-EXT MAL+MARG 2.1-3 CM
|
Facility
|
OP
|
$839.00
|
|
|
Service Code
|
CPT 11603
|
| Hospital Charge Code |
9601160302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$371.59 |
| Max. Negotiated Rate |
$797.05 |
| Rate for Payer: Aetna of VT Commercial |
$797.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$751.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$371.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$751.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$713.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$679.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$377.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$667.00
|
| Rate for Payer: Cash Price |
$419.50
|
| Rate for Payer: Cigna Commercial |
$671.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$671.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$671.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$377.55
|
| Rate for Payer: Multiplan Commercial |
$780.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$713.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$377.55
|
| Rate for Payer: United Healthcare Commercial |
$797.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$377.55
|
| Rate for Payer: United Healthcare VA CCN |
$377.55
|
|
|
EXC TR-EXT MAL+MARG 2.1-3 CM
|
Professional
|
Both
|
$771.00
|
|
|
Service Code
|
CPT 11603
|
| Hospital Charge Code |
9821160301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$182.35 |
| Max. Negotiated Rate |
$724.74 |
| Rate for Payer: Aetna of VT Commercial |
$724.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$690.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$255.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$337.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$337.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$209.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$337.80
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cash Price |
$385.50
|
| Rate for Payer: Cigna Commercial |
$204.61
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$430.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$430.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$264.58
|
| Rate for Payer: Multiplan Commercial |
$717.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$182.35
|
| Rate for Payer: United Healthcare Commercial |
$280.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.35
|
| Rate for Payer: United Healthcare VA CCN |
$182.35
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
IP
|
$797.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$589.86 |
| Max. Negotiated Rate |
$757.15 |
| Rate for Payer: Aetna of VT Commercial |
$757.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$677.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$669.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$637.60
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$637.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$637.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$637.60
|
| Rate for Payer: Multiplan Commercial |
$741.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$677.45
|
| Rate for Payer: United Healthcare Commercial |
$757.15
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
OP
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9821160401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$639.55 |
| Max. Negotiated Rate |
$1,371.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,371.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$639.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$869.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,227.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,169.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$649.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,147.98
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,155.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$649.80
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,227.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$649.80
|
| Rate for Payer: United Healthcare Commercial |
$1,371.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$649.80
|
| Rate for Payer: United Healthcare VA CCN |
$649.80
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
IP
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9821160401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,068.70 |
| Max. Negotiated Rate |
$1,371.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,371.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,068.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,068.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,227.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,212.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,155.20
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,155.20
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,227.40
|
| Rate for Payer: United Healthcare Commercial |
$1,371.80
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Professional
|
Both
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$1,357.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,357.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$206.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$280.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$230.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.06
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$224.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.43
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$284.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare Commercial |
$307.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare VA CCN |
$200.00
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
OP
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$639.55 |
| Max. Negotiated Rate |
$1,371.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,371.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$639.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$869.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,227.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,169.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$649.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,147.98
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,155.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$649.80
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,227.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$649.80
|
| Rate for Payer: United Healthcare Commercial |
$1,371.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$649.80
|
| Rate for Payer: United Healthcare VA CCN |
$649.80
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
OP
|
$648.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
5101160401
|
|
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 TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
OP
|
$797.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$352.99 |
| Max. Negotiated Rate |
$757.15 |
| Rate for Payer: Aetna of VT Commercial |
$757.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$714.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$352.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$714.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$479.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$677.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$645.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$633.62
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$637.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$637.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$637.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$358.65
|
| Rate for Payer: Multiplan Commercial |
$741.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$677.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$358.65
|
| Rate for Payer: United Healthcare Commercial |
$757.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$358.65
|
| Rate for Payer: United Healthcare VA CCN |
$358.65
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
IP
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,068.70 |
| Max. Negotiated Rate |
$1,371.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,371.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,068.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,068.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,227.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,212.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,155.20
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,155.20
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,227.40
|
| Rate for Payer: United Healthcare Commercial |
$1,371.80
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Professional
|
Both
|
$1,444.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9821160401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$1,357.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,357.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$206.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,293.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$280.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$230.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.06
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cash Price |
$722.00
|
| Rate for Payer: Cigna Commercial |
$224.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.43
|
| Rate for Payer: Multiplan Commercial |
$1,342.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$284.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare Commercial |
$307.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare VA CCN |
$200.00
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Professional
|
Both
|
$648.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
5101160401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$200.00 |
| 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 |
$206.00
|
| 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 |
$280.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$230.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.06
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial |
$224.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.43
|
| Rate for Payer: Multiplan Commercial |
$602.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$284.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare Commercial |
$307.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare VA CCN |
$200.00
|
|
|
EXC TR-EXT MAL+MARG 3.1-4 CM
|
Facility
|
IP
|
$648.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
5101160401
|
|
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 TR-EXT MAL+MARG 3.1-4 CM
|
Professional
|
Both
|
$797.00
|
|
|
Service Code
|
CPT 11604
|
| Hospital Charge Code |
9601160402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$749.18 |
| Rate for Payer: Aetna of VT Commercial |
$749.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$714.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$206.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$714.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$280.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$376.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$230.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.06
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$224.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$294.43
|
| Rate for Payer: Multiplan Commercial |
$741.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$284.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare Commercial |
$307.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.00
|
| Rate for Payer: United Healthcare VA CCN |
$200.00
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
OP
|
$2,429.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9601160601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,075.80 |
| Max. Negotiated Rate |
$2,307.55 |
| Rate for Payer: Aetna of VT Commercial |
$2,307.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,075.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,462.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,064.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,967.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,093.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,931.06
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: Cigna Commercial |
$1,943.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,943.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,943.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,093.05
|
| Rate for Payer: Multiplan Commercial |
$2,258.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,064.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,093.05
|
| Rate for Payer: United Healthcare Commercial |
$2,307.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,093.05
|
| Rate for Payer: United Healthcare VA CCN |
$1,093.05
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
IP
|
$1,440.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
5101160601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,065.74 |
| Max. Negotiated Rate |
$1,368.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,368.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,065.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,065.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,224.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,209.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,152.00
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cigna Commercial |
$1,152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,152.00
|
| Rate for Payer: Multiplan Commercial |
$1,339.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare Commercial |
$1,368.00
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Professional
|
Both
|
$2,429.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9601160601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$293.22 |
| Max. Negotiated Rate |
$2,283.26 |
| Rate for Payer: Aetna of VT Commercial |
$2,283.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$302.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$410.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$337.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$537.51
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: Cigna Commercial |
$330.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$693.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$693.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$421.05
|
| Rate for Payer: Multiplan Commercial |
$2,258.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$416.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare Commercial |
$451.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare VA CCN |
$293.22
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Professional
|
Both
|
$1,524.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9821160601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$293.22 |
| Max. Negotiated Rate |
$1,432.56 |
| Rate for Payer: Aetna of VT Commercial |
$1,432.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,365.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$302.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,365.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$410.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$337.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$537.51
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$330.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$693.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$693.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$421.05
|
| Rate for Payer: Multiplan Commercial |
$1,417.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$416.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare Commercial |
$451.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare VA CCN |
$293.22
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
OP
|
$990.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9601160602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$438.47 |
| Max. Negotiated Rate |
$940.50 |
| Rate for Payer: Aetna of VT Commercial |
$940.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$886.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$438.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$886.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$595.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$841.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$801.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$445.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$787.05
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$792.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$792.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$792.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$445.50
|
| Rate for Payer: Multiplan Commercial |
$920.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$841.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$445.50
|
| Rate for Payer: United Healthcare Commercial |
$940.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$445.50
|
| Rate for Payer: United Healthcare VA CCN |
$445.50
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
OP
|
$1,524.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9821160601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$674.98 |
| Max. Negotiated Rate |
$1,447.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,447.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,365.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$674.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,365.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$917.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,295.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,234.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$685.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,211.58
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$1,219.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,219.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,219.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$685.80
|
| Rate for Payer: Multiplan Commercial |
$1,417.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,295.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$685.80
|
| Rate for Payer: United Healthcare Commercial |
$1,447.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$685.80
|
| Rate for Payer: United Healthcare VA CCN |
$685.80
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
OP
|
$1,440.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
5101160601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$637.78 |
| Max. Negotiated Rate |
$1,368.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,368.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,290.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$637.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,290.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$866.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,224.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,166.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$648.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,144.80
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cigna Commercial |
$1,152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,152.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$648.00
|
| Rate for Payer: Multiplan Commercial |
$1,339.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,224.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$648.00
|
| Rate for Payer: United Healthcare Commercial |
$1,368.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$648.00
|
| Rate for Payer: United Healthcare VA CCN |
$648.00
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Professional
|
Both
|
$1,440.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
5101160601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$293.22 |
| Max. Negotiated Rate |
$1,353.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,353.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,290.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$302.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,290.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$410.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$537.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$337.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$537.51
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cigna Commercial |
$330.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$693.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$693.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$421.05
|
| Rate for Payer: Multiplan Commercial |
$1,339.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$416.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare Commercial |
$451.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$293.22
|
| Rate for Payer: United Healthcare VA CCN |
$293.22
|
|
|
EXC TR-EXT MAL+MARG >4 CM
|
Facility
|
IP
|
$2,429.00
|
|
|
Service Code
|
CPT 11606
|
| Hospital Charge Code |
9601160601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,797.70 |
| Max. Negotiated Rate |
$2,307.55 |
| Rate for Payer: Aetna of VT Commercial |
$2,307.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,797.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,797.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,064.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,040.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,943.20
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: Cigna Commercial |
$1,943.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,943.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,943.20
|
| Rate for Payer: Multiplan Commercial |
$2,258.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,064.65
|
| Rate for Payer: United Healthcare Commercial |
$2,307.55
|
|
