|
OB US >= 14 WKS SNGL FETUS
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 76805
|
| Hospital Charge Code |
9607680502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$128.42 |
| Max. Negotiated Rate |
$385.40 |
| Rate for Payer: Aetna of VT Commercial |
$206.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$385.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$132.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$385.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$179.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$209.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$209.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$147.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$209.87
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$197.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$206.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$206.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$128.42
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$182.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$128.42
|
| Rate for Payer: United Healthcare Commercial |
$197.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.42
|
| Rate for Payer: United Healthcare VA CCN |
$128.42
|
|
|
OB US >= 14 WKS SNGL FETUS
|
Facility
|
IP
|
$831.00
|
|
|
Service Code
|
CPT 76805
|
| Hospital Charge Code |
5107680501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$615.02 |
| Max. Negotiated Rate |
$789.45 |
| Rate for Payer: Aetna of VT Commercial |
$789.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$615.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$615.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$706.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$698.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$664.80
|
| Rate for Payer: Cash Price |
$415.50
|
| Rate for Payer: Cigna Commercial |
$664.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$664.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$664.80
|
| Rate for Payer: Multiplan Commercial |
$772.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$706.35
|
| Rate for Payer: United Healthcare Commercial |
$789.45
|
|
|
OB US >= 14 WKS SNGL FETUS
|
Professional
|
Both
|
$438.00
|
|
|
Service Code
|
CPT 76805
|
| Hospital Charge Code |
5107680501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$128.42 |
| Max. Negotiated Rate |
$411.72 |
| Rate for Payer: Aetna of VT Commercial |
$411.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$385.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$132.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$385.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$179.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$209.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$209.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$147.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$209.87
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cigna Commercial |
$197.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$206.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$206.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$128.42
|
| Rate for Payer: Multiplan Commercial |
$407.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$182.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$128.42
|
| Rate for Payer: United Healthcare Commercial |
$197.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.42
|
| Rate for Payer: United Healthcare VA CCN |
$128.42
|
|
|
OB US >= 14 WKS SNGL FETUS
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
CPT 76805
|
| Hospital Charge Code |
9607680501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$844.45 |
| Max. Negotiated Rate |
$1,083.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,083.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$844.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$844.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$969.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$958.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$912.80
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cigna Commercial |
$912.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$912.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$912.80
|
| Rate for Payer: Multiplan Commercial |
$1,061.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$969.85
|
| Rate for Payer: United Healthcare Commercial |
$1,083.95
|
|
|
OB US >= 14 WKS SNGL FETUS
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
CPT 76805
|
| Hospital Charge Code |
9607680501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$505.35 |
| Max. Negotiated Rate |
$1,083.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,083.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,022.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$505.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,022.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$686.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$969.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$924.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$513.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$907.10
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cigna Commercial |
$912.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$912.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$912.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$513.45
|
| Rate for Payer: Multiplan Commercial |
$1,061.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$969.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$513.45
|
| Rate for Payer: United Healthcare Commercial |
$1,083.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$513.45
|
| Rate for Payer: United Healthcare VA CCN |
$513.45
|
|
|
OCRELIZUMAB
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
636J235001
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$158.98 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
OCRELIZUMAB
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
636J235001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
OCRELIZUMAB 300MG/10ML 340B
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
636J235002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
OCRELIZUMAB 300MG/10ML 340B
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
636J235002
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$158.98 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
OCRELIZUMAB 300 MG/10 ML VIAL
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350 TB
|
| Hospital Charge Code |
636J235002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
OCRELIZUMAB 300 MG/10 ML VIAL
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J2350 TB
|
| Hospital Charge Code |
636J235002
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$158.98 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$158.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$196.13 |
| Max. Negotiated Rate |
$251.75 |
| Rate for Payer: Aetna of VT Commercial |
$251.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$196.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$196.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$222.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.00
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.00
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.25
|
| Rate for Payer: United Healthcare Commercial |
$251.75
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$117.37 |
| Max. Negotiated Rate |
$251.75 |
| Rate for Payer: Aetna of VT Commercial |
$251.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$117.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$159.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$119.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$210.68
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$119.25
|
| Rate for Payer: United Healthcare Commercial |
$251.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$119.25
|
| Rate for Payer: United Healthcare VA CCN |
$119.25
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
5109924301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.28 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$79.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$142.31
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.55
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.55
|
| Rate for Payer: United Healthcare VA CCN |
$80.55
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
5109924301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.91 |
| Max. Negotiated Rate |
$212.81 |
| Rate for Payer: Aetna of VT Commercial |
$168.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.81
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$90.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.13
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: United Healthcare Commercial |
$152.15
|
| Rate for Payer: United Healthcare VA CCN |
$86.91
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$86.91 |
| Max. Negotiated Rate |
$249.10 |
| Rate for Payer: Aetna of VT Commercial |
$249.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.81
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$90.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.13
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: United Healthcare Commercial |
$225.25
|
| Rate for Payer: United Healthcare VA CCN |
$86.91
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
5109924301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.48 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna of VT Commercial |
$170.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$150.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.20
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.20
|
| Rate for Payer: Multiplan Commercial |
$166.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.15
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Professional
|
Both
|
$444.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$86.91 |
| Max. Negotiated Rate |
$417.36 |
| Rate for Payer: Aetna of VT Commercial |
$417.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$212.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.81
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$90.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.13
|
| Rate for Payer: Multiplan Commercial |
$412.92
|
| Rate for Payer: United Healthcare Commercial |
$377.40
|
| Rate for Payer: United Healthcare VA CCN |
$86.91
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$196.65 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna of VT Commercial |
$421.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$267.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$377.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$359.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$199.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.98
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$199.80
|
| Rate for Payer: Multiplan Commercial |
$412.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$377.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$199.80
|
| Rate for Payer: United Healthcare Commercial |
$421.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$199.80
|
| Rate for Payer: United Healthcare VA CCN |
$199.80
|
|
|
OFFICE CONSLT NEW/EST PT 30 M
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
9609924301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$328.60 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna of VT Commercial |
$421.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$377.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$372.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$355.20
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.20
|
| Rate for Payer: Multiplan Commercial |
$412.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$377.40
|
| Rate for Payer: United Healthcare Commercial |
$421.80
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$138.63 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Aetna of VT Commercial |
$297.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$280.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$138.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$280.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$188.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$266.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$253.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$140.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$248.84
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cigna Commercial |
$250.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$250.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$250.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$140.85
|
| Rate for Payer: Multiplan Commercial |
$291.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$266.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$140.85
|
| Rate for Payer: United Healthcare Commercial |
$297.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.85
|
| Rate for Payer: United Healthcare VA CCN |
$140.85
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$294.22 |
| Rate for Payer: Aetna of VT Commercial |
$294.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$139.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$45.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$189.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$236.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$236.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$155.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$236.30
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cigna Commercial |
$147.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$279.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$279.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$171.82
|
| Rate for Payer: Multiplan Commercial |
$291.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$191.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$135.20
|
| Rate for Payer: United Healthcare Commercial |
$207.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.20
|
| Rate for Payer: United Healthcare VA CCN |
$135.20
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Facility
|
OP
|
$470.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$208.16 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna of VT Commercial |
$446.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$399.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$380.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$211.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$373.65
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cigna Commercial |
$376.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$376.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$376.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$211.50
|
| Rate for Payer: Multiplan Commercial |
$437.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$399.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$211.50
|
| Rate for Payer: United Healthcare Commercial |
$446.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.50
|
| Rate for Payer: United Healthcare VA CCN |
$211.50
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$231.65 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Aetna of VT Commercial |
$297.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$231.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$231.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$266.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$262.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$250.40
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cigna Commercial |
$250.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$250.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$250.40
|
| Rate for Payer: Multiplan Commercial |
$291.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$266.05
|
| Rate for Payer: United Healthcare Commercial |
$297.35
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$347.85 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna of VT Commercial |
$446.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$347.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$347.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$399.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$394.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.00
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cigna Commercial |
$376.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$376.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$376.00
|
| Rate for Payer: Multiplan Commercial |
$437.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$399.50
|
| Rate for Payer: United Healthcare Commercial |
$446.50
|
|
