|
INITIAL PREVENTIVE EXAM
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
510G040201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$140.62 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Aetna of VT Commercial |
$180.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$161.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$152.00
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.00
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.50
|
| Rate for Payer: United Healthcare Commercial |
$180.50
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
960G040201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$140.62 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Aetna of VT Commercial |
$180.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$161.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$152.00
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.00
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.50
|
| Rate for Payer: United Healthcare Commercial |
$180.50
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
960G040201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.15 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Aetna of VT Commercial |
$180.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$114.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$161.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$153.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$85.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$151.05
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$180.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.50
|
| Rate for Payer: United Healthcare VA CCN |
$85.50
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
IP
|
$473.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
960G040202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$350.07 |
| Max. Negotiated Rate |
$449.35 |
| Rate for Payer: Aetna of VT Commercial |
$449.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$350.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$350.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$397.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.40
|
| Rate for Payer: Cash Price |
$236.50
|
| Rate for Payer: Cigna Commercial |
$378.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.40
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.05
|
| Rate for Payer: United Healthcare Commercial |
$449.35
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
510G040201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$123.08 |
| Max. Negotiated Rate |
$255.61 |
| Rate for Payer: Aetna of VT Commercial |
$178.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$126.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$172.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$207.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$207.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$207.91
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$255.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$255.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.76
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$174.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$123.08
|
| Rate for Payer: United Healthcare Commercial |
$189.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$123.08
|
| Rate for Payer: United Healthcare VA CCN |
$123.08
|
|
|
INIT NB EM PER DAY HOSP
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
CPT 99460
|
| Hospital Charge Code |
9879946001
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$153.69 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Aetna of VT Commercial |
$329.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$153.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$208.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$294.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$281.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$156.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$275.87
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$277.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$277.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$277.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$156.15
|
| Rate for Payer: Multiplan Commercial |
$322.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$156.15
|
| Rate for Payer: United Healthcare Commercial |
$329.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.15
|
| Rate for Payer: United Healthcare VA CCN |
$156.15
|
|
|
INIT NB EM PER DAY HOSP
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
CPT 99460
|
| Hospital Charge Code |
9879946001
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$86.45 |
| Max. Negotiated Rate |
$326.18 |
| Rate for Payer: Aetna of VT Commercial |
$326.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$89.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$121.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$99.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.91
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$94.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$140.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$140.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$86.45
|
| Rate for Payer: Multiplan Commercial |
$322.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$122.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$86.45
|
| Rate for Payer: United Healthcare Commercial |
$132.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.45
|
| Rate for Payer: United Healthcare VA CCN |
$86.45
|
|
|
INIT NB EM PER DAY HOSP
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
CPT 99460
|
| Hospital Charge Code |
9879946001
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$256.81 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Aetna of VT Commercial |
$329.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$256.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$256.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$294.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$291.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$277.60
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$277.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$277.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$277.60
|
| Rate for Payer: Multiplan Commercial |
$322.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.95
|
| Rate for Payer: United Healthcare Commercial |
$329.65
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$147.04 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$268.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$263.94
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare VA CCN |
$149.40
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$77.36 |
| Max. Negotiated Rate |
$312.08 |
| Rate for Payer: Aetna of VT Commercial |
$312.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$203.16
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$79.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.32
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: United Healthcare Commercial |
$282.20
|
| Rate for Payer: United Healthcare VA CCN |
$77.36
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
5109938201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$284.34 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$284.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$386.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$520.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$288.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$510.39
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$288.90
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare VA CCN |
$288.90
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$147.04 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$268.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$263.94
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare VA CCN |
$149.40
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$245.71 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$278.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.60
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$245.71 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$278.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.60
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
5109938201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$539.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$513.60
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
9609938202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$77.36 |
| Max. Negotiated Rate |
$312.08 |
| Rate for Payer: Aetna of VT Commercial |
$312.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$203.16
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$79.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.32
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: United Healthcare Commercial |
$282.20
|
| Rate for Payer: United Healthcare VA CCN |
$77.36
|
|
|
INIT PM E/M NEW PAT 1-4 YRS
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
CPT 99382
|
| Hospital Charge Code |
5109938201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.36 |
| Max. Negotiated Rate |
$603.48 |
| Rate for Payer: Aetna of VT Commercial |
$603.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$203.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$203.16
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$79.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.32
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: United Healthcare Commercial |
$545.70
|
| Rate for Payer: United Healthcare VA CCN |
$77.36
|
|
|
INIT PM E/M NEW PAT INFANT
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
5109938101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$603.48 |
| Rate for Payer: Aetna of VT Commercial |
$603.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.69
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$104.47
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: United Healthcare Commercial |
$545.70
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
INIT PM E/M NEW PAT INFANT
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
5109938101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$284.34 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$284.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$575.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$386.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$520.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$288.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$510.39
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$288.90
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$288.90
|
| Rate for Payer: United Healthcare VA CCN |
$288.90
|
|
|
INIT PM E/M NEW PAT INFANT
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
5109938101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$609.90 |
| Rate for Payer: Aetna of VT Commercial |
$609.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$475.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$545.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$539.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$513.60
|
| Rate for Payer: Cash Price |
$321.00
|
| Rate for Payer: Cigna Commercial |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$513.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$513.60
|
| Rate for Payer: Multiplan Commercial |
$597.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$545.70
|
| Rate for Payer: United Healthcare Commercial |
$609.90
|
|
|
INIT PM E/M NEW PAT INFANT
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
9609938101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$312.08 |
| Rate for Payer: Aetna of VT Commercial |
$312.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.69
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$104.47
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: United Healthcare Commercial |
$282.20
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
INIT PM E/M NEW PAT INFANT
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
9609938101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$147.04 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$297.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$199.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$268.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$149.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$263.94
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.40
|
| Rate for Payer: United Healthcare VA CCN |
$149.40
|
|
|
INIT PM E/M NEW PAT INFANT
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
9609938101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$245.71 |
| Max. Negotiated Rate |
$315.40 |
| Rate for Payer: Aetna of VT Commercial |
$315.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$245.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$282.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$278.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$265.60
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$265.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$265.60
|
| Rate for Payer: Multiplan Commercial |
$308.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$282.20
|
| Rate for Payer: United Healthcare Commercial |
$315.40
|
|
|
INIT PM E/M NEW PAT INFANT
|
Professional
|
Both
|
$318.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
9609938102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$298.92 |
| Rate for Payer: Aetna of VT Commercial |
$298.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$284.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$284.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.69
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$104.47
|
| Rate for Payer: Multiplan Commercial |
$295.74
|
| Rate for Payer: United Healthcare Commercial |
$270.30
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
INIT PM E/M NEW PAT INFANT
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 99381
|
| Hospital Charge Code |
9609938102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$140.84 |
| Max. Negotiated Rate |
$302.10 |
| Rate for Payer: Aetna of VT Commercial |
$302.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$284.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$140.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$284.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$191.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$270.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$257.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$143.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$252.81
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$254.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$254.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$254.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$143.10
|
| Rate for Payer: Multiplan Commercial |
$295.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$270.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$143.10
|
| Rate for Payer: United Healthcare Commercial |
$302.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.10
|
| Rate for Payer: United Healthcare VA CCN |
$143.10
|
|
