|
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
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
5109938401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna of VT Commercial |
$228.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$178.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$178.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$204.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$202.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$192.80
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.80
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$204.85
|
| Rate for Payer: United Healthcare Commercial |
$228.95
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$246.70 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna of VT Commercial |
$529.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$246.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$335.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$473.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$451.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$250.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$442.81
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$445.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$250.65
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$473.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$250.65
|
| Rate for Payer: United Healthcare Commercial |
$529.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$250.65
|
| Rate for Payer: United Healthcare VA CCN |
$250.65
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
IP
|
$316.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$233.87 |
| Max. Negotiated Rate |
$300.20 |
| Rate for Payer: Aetna of VT Commercial |
$300.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$233.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$233.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$252.80
|
| Rate for Payer: Cash Price |
$158.00
|
| Rate for Payer: Cigna Commercial |
$252.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.80
|
| Rate for Payer: Multiplan Commercial |
$293.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.60
|
| Rate for Payer: United Healthcare Commercial |
$300.20
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$412.24 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna of VT Commercial |
$529.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$412.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$412.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$473.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$467.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$445.60
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$445.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$445.60
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$473.45
|
| Rate for Payer: United Healthcare Commercial |
$529.15
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$523.58 |
| Rate for Payer: Aetna of VT Commercial |
$523.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$499.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cash Price |
$278.50
|
| Rate for Payer: Cigna Commercial |
$100.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$206.24
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$206.24
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.26
|
| Rate for Payer: Multiplan Commercial |
$518.01
|
| Rate for Payer: United Healthcare Commercial |
$473.45
|
| Rate for Payer: United Healthcare VA CCN |
$96.46
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
5109938401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna of VT Commercial |
$228.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$106.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$145.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$204.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$108.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$191.59
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$108.45
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$204.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$108.45
|
| Rate for Payer: United Healthcare Commercial |
$228.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.45
|
| Rate for Payer: United Healthcare VA CCN |
$108.45
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
5109938401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$226.54 |
| Rate for Payer: Aetna of VT Commercial |
$226.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$100.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$206.24
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$206.24
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.26
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: United Healthcare Commercial |
$204.85
|
| Rate for Payer: United Healthcare VA CCN |
$96.46
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Facility
|
OP
|
$316.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$139.96 |
| Max. Negotiated Rate |
$300.20 |
| Rate for Payer: Aetna of VT Commercial |
$300.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$283.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$139.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$283.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$190.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$255.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$251.22
|
| Rate for Payer: Cash Price |
$158.00
|
| Rate for Payer: Cigna Commercial |
$252.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.20
|
| Rate for Payer: Multiplan Commercial |
$293.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.20
|
| Rate for Payer: United Healthcare Commercial |
$300.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.20
|
| Rate for Payer: United Healthcare VA CCN |
$142.20
|
|
|
INIT PREVT MED NEW PT 12-17 YR
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
CPT 99384
|
| Hospital Charge Code |
9609938402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$297.04 |
| Rate for Payer: Aetna of VT Commercial |
$297.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$283.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$283.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$158.00
|
| Rate for Payer: Cash Price |
$158.00
|
| Rate for Payer: Cigna Commercial |
$100.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$206.24
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$206.24
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.26
|
| Rate for Payer: Multiplan Commercial |
$293.88
|
| Rate for Payer: United Healthcare Commercial |
$268.60
|
| Rate for Payer: United Healthcare VA CCN |
$96.46
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
5109938501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.61 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of VT Commercial |
$85.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$66.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$66.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$76.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$75.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$72.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$83.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$76.50
|
| Rate for Payer: United Healthcare Commercial |
$85.50
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$92.64 |
| Max. Negotiated Rate |
$216.23 |
| Rate for Payer: Aetna of VT Commercial |
$211.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$201.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$201.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$95.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$123.70
|
| Rate for Payer: Multiplan Commercial |
$209.25
|
| Rate for Payer: United Healthcare Commercial |
$191.25
|
| Rate for Payer: United Healthcare VA CCN |
$92.64
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$99.65 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna of VT Commercial |
$213.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$201.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$99.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$201.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$135.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$191.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$182.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$101.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$178.88
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$180.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$101.25
|
| Rate for Payer: Multiplan Commercial |
$209.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$191.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$213.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$101.25
|
| Rate for Payer: United Healthcare VA CCN |
$101.25
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
5109938501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$216.23 |
| Rate for Payer: Aetna of VT Commercial |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$95.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$123.70
|
| Rate for Payer: Multiplan Commercial |
$83.70
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
| Rate for Payer: United Healthcare VA CCN |
$92.64
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$166.52 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna of VT Commercial |
$213.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$166.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$166.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$191.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$189.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$180.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$180.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$209.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$191.25
|
| Rate for Payer: United Healthcare Commercial |
$213.75
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$99.91 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$92.64 |
| Max. Negotiated Rate |
$216.23 |
| Rate for Payer: Aetna of VT Commercial |
$126.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$216.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.23
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$95.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$123.70
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: United Healthcare Commercial |
$114.75
|
| Rate for Payer: United Healthcare VA CCN |
$92.64
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
9609938502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$59.79 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$59.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$81.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.33
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare VA CCN |
$60.75
|
|
|
INIT PREVT MED NEW PT 18-39 YR
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 99385
|
| Hospital Charge Code |
5109938501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$39.86 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of VT Commercial |
$85.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$76.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$71.55
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$72.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$83.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$76.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.50
|
| Rate for Payer: United Healthcare Commercial |
$85.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.50
|
| Rate for Payer: United Healthcare VA CCN |
$40.50
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Facility
|
IP
|
$373.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
9609938702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$276.06 |
| Max. Negotiated Rate |
$354.35 |
| Rate for Payer: Aetna of VT Commercial |
$354.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$313.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$298.40
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$298.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$298.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$298.40
|
| Rate for Payer: Multiplan Commercial |
$346.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.05
|
| Rate for Payer: United Healthcare Commercial |
$354.35
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
5109938701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.62 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Aetna of VT Commercial |
$164.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$76.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$104.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$137.53
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$138.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$138.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$138.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$77.85
|
| Rate for Payer: Multiplan Commercial |
$160.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$77.85
|
| Rate for Payer: United Healthcare Commercial |
$164.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.85
|
| Rate for Payer: United Healthcare VA CCN |
$77.85
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Professional
|
Both
|
$373.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
9609938702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$120.33 |
| Max. Negotiated Rate |
$350.62 |
| Rate for Payer: Aetna of VT Commercial |
$350.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$334.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$334.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$275.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$275.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$275.44
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$124.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$250.99
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$250.99
|
| Rate for Payer: Martins Point Health Care Commercial |
$154.85
|
| Rate for Payer: Multiplan Commercial |
$346.89
|
| Rate for Payer: United Healthcare Commercial |
$317.05
|
| Rate for Payer: United Healthcare VA CCN |
$120.33
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
9609938701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$241.38 |
| Max. Negotiated Rate |
$517.75 |
| Rate for Payer: Aetna of VT Commercial |
$517.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$488.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$241.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$488.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$328.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$463.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$441.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$245.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$433.27
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$436.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$436.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$436.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$245.25
|
| Rate for Payer: Multiplan Commercial |
$506.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$463.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$245.25
|
| Rate for Payer: United Healthcare Commercial |
$517.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$245.25
|
| Rate for Payer: United Healthcare VA CCN |
$245.25
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Facility
|
OP
|
$373.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
9609938702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$165.20 |
| Max. Negotiated Rate |
$354.35 |
| Rate for Payer: Aetna of VT Commercial |
$354.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$334.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$165.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$334.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$317.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$302.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$167.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$296.54
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$298.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$298.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$298.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$167.85
|
| Rate for Payer: Multiplan Commercial |
$346.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$317.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$167.85
|
| Rate for Payer: United Healthcare Commercial |
$354.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$167.85
|
| Rate for Payer: United Healthcare VA CCN |
$167.85
|
|
|
INIT PREVT MED NEW PT 65YR>
|
Facility
|
IP
|
$545.00
|
|
|
Service Code
|
CPT 99387
|
| Hospital Charge Code |
9609938701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$403.35 |
| Max. Negotiated Rate |
$517.75 |
| Rate for Payer: Aetna of VT Commercial |
$517.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$403.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$403.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$463.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$457.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$436.00
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$436.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$436.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$436.00
|
| Rate for Payer: Multiplan Commercial |
$506.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$463.25
|
| Rate for Payer: United Healthcare Commercial |
$517.75
|
|
