|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9821203601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$527.05 |
| Max. Negotiated Rate |
$1,130.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,130.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$716.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,011.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$963.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$535.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$946.05
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$952.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$535.50
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,011.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$535.50
|
| Rate for Payer: United Healthcare Commercial |
$1,130.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$535.50
|
| Rate for Payer: United Healthcare VA CCN |
$535.50
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
IP
|
$3,220.91
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
4501203601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,383.80 |
| Max. Negotiated Rate |
$3,059.86 |
| Rate for Payer: Aetna of VT Commercial |
$3,059.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,383.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,383.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,737.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,705.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,576.73
|
| Rate for Payer: Cash Price |
$1,610.45
|
| Rate for Payer: Cigna Commercial |
$2,576.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,576.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,576.73
|
| Rate for Payer: Multiplan Commercial |
$2,995.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,737.77
|
| Rate for Payer: United Healthcare Commercial |
$3,059.86
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$1,118.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,118.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$269.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$366.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$301.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$596.31
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$477.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$407.55
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$372.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare Commercial |
$403.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare VA CCN |
$262.05
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203601
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9821203601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$1,118.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,118.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$269.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$366.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$301.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$596.31
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$477.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$407.55
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$372.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare Commercial |
$403.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare VA CCN |
$262.05
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
IP
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9821203601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$880.72 |
| Max. Negotiated Rate |
$1,130.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,130.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$880.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$880.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,011.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$999.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$952.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$952.00
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,011.50
|
| Rate for Payer: United Healthcare Commercial |
$1,130.50
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
IP
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$880.72 |
| Max. Negotiated Rate |
$1,130.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,130.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$880.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$880.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,011.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$999.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$952.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$952.00
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,011.50
|
| Rate for Payer: United Healthcare Commercial |
$1,130.50
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$3,220.91
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
4501203601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,426.54 |
| Max. Negotiated Rate |
$3,059.86 |
| Rate for Payer: Aetna of VT Commercial |
$3,059.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,885.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,426.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,885.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,938.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,737.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,608.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,449.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,560.62
|
| Rate for Payer: Cash Price |
$1,610.45
|
| Rate for Payer: Cigna Commercial |
$2,576.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,576.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,576.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,449.41
|
| Rate for Payer: Multiplan Commercial |
$2,995.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,737.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,449.41
|
| Rate for Payer: United Healthcare Commercial |
$3,059.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,449.41
|
| Rate for Payer: United Healthcare VA CCN |
$1,449.41
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$1,190.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$527.05 |
| Max. Negotiated Rate |
$1,130.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,130.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$527.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,066.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$716.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,011.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$963.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$535.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$946.05
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$952.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$952.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$535.50
|
| Rate for Payer: Multiplan Commercial |
$1,106.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,011.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$535.50
|
| Rate for Payer: United Healthcare Commercial |
$1,130.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$535.50
|
| Rate for Payer: United Healthcare VA CCN |
$535.50
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
9811203601
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$672.19 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$269.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$366.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$596.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$301.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$596.31
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$477.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$407.55
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$372.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare Commercial |
$403.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$262.05
|
| Rate for Payer: United Healthcare VA CCN |
$262.05
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
IP
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$452.20 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$513.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.80
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Professional
|
Both
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$143.55 |
| Max. Negotiated Rate |
$574.34 |
| Rate for Payer: Aetna of VT Commercial |
$574.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$324.27
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$262.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$402.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$402.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.94
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare VA CCN |
$143.55
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Professional
|
Both
|
$958.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$143.55 |
| Max. Negotiated Rate |
$900.52 |
| Rate for Payer: Aetna of VT Commercial |
$900.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$858.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$858.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$324.27
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$262.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$402.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$402.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.94
|
| Rate for Payer: Multiplan Commercial |
$890.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare VA CCN |
$143.55
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
OP
|
$958.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$424.30 |
| Max. Negotiated Rate |
$910.10 |
| Rate for Payer: Aetna of VT Commercial |
$910.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$858.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$424.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$858.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$576.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$814.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$775.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$431.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$761.61
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$766.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$766.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$766.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$431.10
|
| Rate for Payer: Multiplan Commercial |
$890.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$814.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$431.10
|
| Rate for Payer: United Healthcare Commercial |
$910.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$431.10
|
| Rate for Payer: United Healthcare VA CCN |
$431.10
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
OP
|
$348.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
5101203101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$154.13 |
| Max. Negotiated Rate |
$330.60 |
| Rate for Payer: Aetna of VT Commercial |
$330.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$311.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$154.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$311.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$209.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$295.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$281.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$156.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$276.66
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$278.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$278.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$278.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$156.60
|
| Rate for Payer: Multiplan Commercial |
$323.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$295.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$156.60
|
| Rate for Payer: United Healthcare Commercial |
$330.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.60
|
| Rate for Payer: United Healthcare VA CCN |
$156.60
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
5101203101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$257.55 |
| Max. Negotiated Rate |
$330.60 |
| Rate for Payer: Aetna of VT Commercial |
$330.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$295.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$292.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$278.40
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$278.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$278.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$278.40
|
| Rate for Payer: Multiplan Commercial |
$323.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$295.80
|
| Rate for Payer: United Healthcare Commercial |
$330.60
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$270.61 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$270.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$494.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$274.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$485.75
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$274.95
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare VA CCN |
$274.95
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9821203101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$270.61 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$270.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$367.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$494.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$274.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$485.75
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$274.95
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$274.95
|
| Rate for Payer: United Healthcare VA CCN |
$274.95
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
IP
|
$958.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9601203101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$709.02 |
| Max. Negotiated Rate |
$910.10 |
| Rate for Payer: Aetna of VT Commercial |
$910.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$709.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$709.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$814.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$804.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$766.40
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$766.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$766.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$766.40
|
| Rate for Payer: Multiplan Commercial |
$890.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$814.30
|
| Rate for Payer: United Healthcare Commercial |
$910.10
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Facility
|
IP
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9821203101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$452.20 |
| Max. Negotiated Rate |
$580.45 |
| Rate for Payer: Aetna of VT Commercial |
$580.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$452.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$519.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$513.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$488.80
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$488.80
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$519.35
|
| Rate for Payer: United Healthcare Commercial |
$580.45
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Professional
|
Both
|
$611.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
9821203101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$143.55 |
| Max. Negotiated Rate |
$574.34 |
| Rate for Payer: Aetna of VT Commercial |
$574.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$547.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$324.27
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cash Price |
$305.50
|
| Rate for Payer: Cigna Commercial |
$262.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$402.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$402.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.94
|
| Rate for Payer: Multiplan Commercial |
$568.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare VA CCN |
$143.55
|
|
|
INTMD RPR S/A/T/EXT 2.5 CM/<
|
Professional
|
Both
|
$348.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
5101203101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$143.55 |
| Max. Negotiated Rate |
$402.18 |
| Rate for Payer: Aetna of VT Commercial |
$327.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$311.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$147.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$311.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$200.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$324.27
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$262.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$402.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$402.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.94
|
| Rate for Payer: Multiplan Commercial |
$323.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$143.55
|
| Rate for Payer: United Healthcare VA CCN |
$143.55
|
|
|
INTMD RPR S/A/T/EXT 2.6-7.5
|
Facility
|
OP
|
$707.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
9821203201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$313.13 |
| Max. Negotiated Rate |
$671.65 |
| Rate for Payer: Aetna of VT Commercial |
$671.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$633.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$313.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$633.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$425.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$600.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$572.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$318.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$562.07
|
| Rate for Payer: Cash Price |
$353.50
|
| Rate for Payer: Cigna Commercial |
$565.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$565.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$565.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$318.15
|
| Rate for Payer: Multiplan Commercial |
$657.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$318.15
|
| Rate for Payer: United Healthcare Commercial |
$671.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$318.15
|
| Rate for Payer: United Healthcare VA CCN |
$318.15
|
|
|
INTMD RPR S/A/T/EXT 2.6-7.5
|
Professional
|
Both
|
$707.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
9821203201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$180.81 |
| Max. Negotiated Rate |
$664.58 |
| Rate for Payer: Aetna of VT Commercial |
$664.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$633.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$186.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$633.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$253.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$402.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$207.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$402.27
|
| Rate for Payer: Cash Price |
$353.50
|
| Rate for Payer: Cash Price |
$353.50
|
| Rate for Payer: Cigna Commercial |
$329.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$467.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$467.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$288.09
|
| Rate for Payer: Multiplan Commercial |
$657.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$256.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$180.81
|
| Rate for Payer: United Healthcare Commercial |
$278.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$180.81
|
| Rate for Payer: United Healthcare VA CCN |
$180.81
|
|
|
INTMD RPR S/A/T/EXT 2.6-7.5
|
Facility
|
IP
|
$707.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
9821203201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$523.25 |
| Max. Negotiated Rate |
$671.65 |
| Rate for Payer: Aetna of VT Commercial |
$671.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$523.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$523.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$600.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$593.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$565.60
|
| Rate for Payer: Cash Price |
$353.50
|
| Rate for Payer: Cigna Commercial |
$565.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$565.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$565.60
|
| Rate for Payer: Multiplan Commercial |
$657.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.95
|
| Rate for Payer: United Healthcare Commercial |
$671.65
|
|
