|
OFFICE/OP EST HIGH MDM 40-54 M
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
5109921501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$279.26 |
| Rate for Payer: Aetna of VT Commercial |
$148.52
|
| 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 |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| 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 |
$146.94
|
| 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
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
9609921501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$441.80 |
| Rate for Payer: Aetna of VT Commercial |
$441.80
|
| 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 |
$235.00
|
| Rate for Payer: Cash Price |
$235.00
|
| 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 |
$437.10
|
| 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
|
$158.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
5109921501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.98 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna of VT Commercial |
$150.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$141.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$141.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$95.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$134.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$125.61
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$126.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$71.10
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$134.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$71.10
|
| Rate for Payer: United Healthcare Commercial |
$150.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.10
|
| Rate for Payer: United Healthcare VA CCN |
$71.10
|
|
|
OFFICE/OP EST HIGH MDM 40-54 M
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
5109921501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.94 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna of VT Commercial |
$150.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$134.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$126.40
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$126.40
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$134.30
|
| Rate for Payer: United Healthcare Commercial |
$150.10
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$179.84 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna of VT Commercial |
$230.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$179.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$179.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$206.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$204.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$194.40
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$194.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$194.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$194.40
|
| Rate for Payer: Multiplan Commercial |
$225.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$206.55
|
| Rate for Payer: United Healthcare Commercial |
$230.85
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$33.44 |
| Max. Negotiated Rate |
$148.52 |
| Rate for Payer: Aetna of VT Commercial |
$148.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$119.40
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$67.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$141.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$141.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.09
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare Commercial |
$95.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare VA CCN |
$62.03
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$69.98 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna of VT Commercial |
$150.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$141.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$141.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$95.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$134.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$125.61
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$126.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$71.10
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$134.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$71.10
|
| Rate for Payer: United Healthcare Commercial |
$150.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.10
|
| Rate for Payer: United Healthcare VA CCN |
$71.10
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$116.94 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna of VT Commercial |
$150.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$134.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$126.40
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$126.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$126.40
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$134.30
|
| Rate for Payer: United Healthcare Commercial |
$150.10
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$107.62 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna of VT Commercial |
$230.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$217.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$107.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$217.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$146.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$206.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$109.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$193.19
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$194.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$194.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$194.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.35
|
| Rate for Payer: Multiplan Commercial |
$225.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$206.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$109.35
|
| Rate for Payer: United Healthcare Commercial |
$230.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.35
|
| Rate for Payer: United Healthcare VA CCN |
$109.35
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
5109921301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.65 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Aetna of VT Commercial |
$81.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$63.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$63.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.80
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$68.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.80
|
| Rate for Payer: Multiplan Commercial |
$79.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.10
|
| Rate for Payer: United Healthcare Commercial |
$81.70
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
5109921301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.09 |
| Max. Negotiated Rate |
$81.70 |
| Rate for Payer: Aetna of VT Commercial |
$81.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$51.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.37
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$68.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.70
|
| Rate for Payer: Multiplan Commercial |
$79.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.70
|
| Rate for Payer: United Healthcare Commercial |
$81.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.70
|
| Rate for Payer: United Healthcare VA CCN |
$38.70
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Professional
|
Both
|
$86.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
5109921301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.44 |
| Max. Negotiated Rate |
$141.43 |
| Rate for Payer: Aetna of VT Commercial |
$80.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$119.40
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$67.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$141.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$141.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.09
|
| Rate for Payer: Multiplan Commercial |
$79.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare Commercial |
$95.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare VA CCN |
$62.03
|
|
|
OFFICE/OP EST LOW MDM 20-29 M
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
9609921301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$33.44 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna of VT Commercial |
$228.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$119.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$119.40
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$67.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$141.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$141.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.09
|
| Rate for Payer: Multiplan Commercial |
$225.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare Commercial |
$95.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.03
|
| Rate for Payer: United Healthcare VA CCN |
$62.03
|
|
|
OFFICE/OP EST MIN PROB
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5109921101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.39 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Aetna of VT Commercial |
$82.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$73.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$69.60
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$69.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$69.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$69.60
|
| Rate for Payer: Multiplan Commercial |
$80.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.95
|
| Rate for Payer: United Healthcare Commercial |
$82.65
|
|
|
OFFICE/OP EST MIN PROB
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5109921101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$82.65 |
| Rate for Payer: Aetna of VT Commercial |
$82.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$70.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$39.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$69.17
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$69.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$69.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$69.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$39.15
|
| Rate for Payer: Multiplan Commercial |
$80.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$39.15
|
| Rate for Payer: United Healthcare Commercial |
$82.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.15
|
| Rate for Payer: United Healthcare VA CCN |
$39.15
|
|
|
OFFICE/OP EST MIN PROB
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5109921101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$81.78 |
| Rate for Payer: Aetna of VT Commercial |
$81.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$36.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.55
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$8.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$36.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$36.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.37
|
| Rate for Payer: Multiplan Commercial |
$80.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.24
|
| Rate for Payer: United Healthcare Commercial |
$12.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.24
|
| Rate for Payer: United Healthcare VA CCN |
$8.24
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$216.20 |
| Rate for Payer: Aetna of VT Commercial |
$216.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$104.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.44
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$99.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.43
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare Commercial |
$140.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare VA CCN |
$91.28
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Professional
|
Both
|
$344.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$323.36 |
| Rate for Payer: Aetna of VT Commercial |
$323.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$104.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.44
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$99.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.43
|
| Rate for Payer: Multiplan Commercial |
$319.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare Commercial |
$140.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare VA CCN |
$91.28
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
5109921401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.49 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna of VT Commercial |
$108.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$51.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$90.63
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$91.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.30
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.30
|
| Rate for Payer: United Healthcare Commercial |
$108.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.30
|
| Rate for Payer: United Healthcare VA CCN |
$51.30
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Aetna of VT Commercial |
$326.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$308.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$152.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$308.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$207.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$292.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$278.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$154.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$273.48
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$275.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$275.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$275.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$154.80
|
| Rate for Payer: Multiplan Commercial |
$319.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$292.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$154.80
|
| Rate for Payer: United Healthcare Commercial |
$326.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.80
|
| Rate for Payer: United Healthcare VA CCN |
$154.80
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
5109921401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.37 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna of VT Commercial |
$108.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$95.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.20
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$91.20
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.90
|
| Rate for Payer: United Healthcare Commercial |
$108.30
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$170.22 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$193.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$254.59 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Aetna of VT Commercial |
$326.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$254.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$254.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$292.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$288.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$275.20
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$275.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$275.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$275.20
|
| Rate for Payer: Multiplan Commercial |
$319.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$292.40
|
| Rate for Payer: United Healthcare Commercial |
$326.80
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
9609921402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$101.87 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.85
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare VA CCN |
$103.50
|
|
|
OFFICE/OP EST MOD MDM 30-39 M
|
Professional
|
Both
|
$114.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
5109921401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.14 |
| Max. Negotiated Rate |
$199.04 |
| Rate for Payer: Aetna of VT Commercial |
$107.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$104.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.44
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$99.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.43
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$129.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare Commercial |
$140.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.28
|
| Rate for Payer: United Healthcare VA CCN |
$91.28
|
|
