|
OFFICE/OP NEW LOW MDM 30-44 M
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9609920302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$194.65 |
| Max. Negotiated Rate |
$249.85 |
| Rate for Payer: Aetna of VT Commercial |
$249.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$223.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$220.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$210.40
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$210.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$210.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$210.40
|
| Rate for Payer: Multiplan Commercial |
$244.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$223.55
|
| Rate for Payer: United Healthcare Commercial |
$249.85
|
|
|
OFFICE/OP NEW LOW MDM 30-44 M
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
9609920301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$49.13 |
| Max. Negotiated Rate |
$383.52 |
| Rate for Payer: Aetna of VT Commercial |
$383.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$49.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$78.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$49.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$168.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$88.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.55
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$83.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$106.15
|
| Rate for Payer: Multiplan Commercial |
$379.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$108.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$76.60
|
| Rate for Payer: United Healthcare Commercial |
$117.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.60
|
| Rate for Payer: United Healthcare VA CCN |
$76.60
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
5109920401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.63 |
| Max. Negotiated Rate |
$259.72 |
| Rate for Payer: Aetna of VT Commercial |
$196.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$175.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$143.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$243.32
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$135.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$259.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$259.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$159.11
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare Commercial |
$192.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare VA CCN |
$125.06
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
5109920401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$154.68 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna of VT Commercial |
$198.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$175.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$167.20
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$167.20
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.65
|
| Rate for Payer: United Healthcare Commercial |
$198.55
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
5109920401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$92.57 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna of VT Commercial |
$198.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$187.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$92.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$187.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$125.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$169.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$166.16
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$167.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.05
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.05
|
| Rate for Payer: United Healthcare Commercial |
$198.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.05
|
| Rate for Payer: United Healthcare VA CCN |
$94.05
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$245.37 |
| Max. Negotiated Rate |
$526.30 |
| Rate for Payer: Aetna of VT Commercial |
$526.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$496.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$245.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$496.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$333.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$470.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$448.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$249.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$440.43
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$443.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$249.30
|
| Rate for Payer: Multiplan Commercial |
$515.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$470.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$249.30
|
| Rate for Payer: United Healthcare Commercial |
$526.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$249.30
|
| Rate for Payer: United Healthcare VA CCN |
$249.30
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$410.02 |
| Max. Negotiated Rate |
$526.30 |
| Rate for Payer: Aetna of VT Commercial |
$526.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$410.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$410.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$470.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$465.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$443.20
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$443.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$443.20
|
| Rate for Payer: Multiplan Commercial |
$515.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$470.90
|
| Rate for Payer: United Healthcare Commercial |
$526.30
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$152.80 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna of VT Commercial |
$327.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$309.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$152.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$309.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$207.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$293.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$279.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$155.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$274.27
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$276.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$276.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$276.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.25
|
| Rate for Payer: Multiplan Commercial |
$320.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$293.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$155.25
|
| Rate for Payer: United Healthcare Commercial |
$327.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.25
|
| Rate for Payer: United Healthcare VA CCN |
$155.25
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Professional
|
Both
|
$554.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.63 |
| Max. Negotiated Rate |
$520.76 |
| Rate for Payer: Aetna of VT Commercial |
$520.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$175.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$143.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$243.32
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$135.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$259.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$259.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$159.11
|
| Rate for Payer: Multiplan Commercial |
$515.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare Commercial |
$192.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare VA CCN |
$125.06
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$255.33 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna of VT Commercial |
$327.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$255.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$255.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$293.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$289.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$276.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$276.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$276.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$320.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$293.25
|
| Rate for Payer: United Healthcare Commercial |
$327.75
|
|
|
OFFICE/OP NEW MOD MDM 45-59 M
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
9609920402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.63 |
| Max. Negotiated Rate |
$324.30 |
| Rate for Payer: Aetna of VT Commercial |
$324.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$175.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$243.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$143.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$243.32
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$135.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$259.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$259.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$159.11
|
| Rate for Payer: Multiplan Commercial |
$320.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare Commercial |
$192.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$125.06
|
| Rate for Payer: United Healthcare VA CCN |
$125.06
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$116.93 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Aetna of VT Commercial |
$250.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$236.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$116.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$236.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$158.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$224.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$213.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$209.88
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$211.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$211.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$211.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.80
|
| Rate for Payer: Multiplan Commercial |
$245.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$224.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$118.80
|
| Rate for Payer: United Healthcare Commercial |
$250.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$118.80
|
| Rate for Payer: United Healthcare VA CCN |
$118.80
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920202
|
|
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 NEW SF MDM 15-29 MIN
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920202
|
|
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 NEW SF MDM 15-29 MIN
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$248.16 |
| Rate for Payer: Aetna of VT Commercial |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$45.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$50.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$113.52
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$48.25
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.52
|
| Rate for Payer: Multiplan Commercial |
$245.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare Commercial |
$67.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare VA CCN |
$44.10
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
5109920201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.19 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Aetna of VT Commercial |
$101.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$90.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$85.60
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$85.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$85.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$85.60
|
| Rate for Payer: Multiplan Commercial |
$99.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$90.95
|
| Rate for Payer: United Healthcare Commercial |
$101.65
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$31.49 |
| 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 |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$45.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$50.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$113.52
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$48.25
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.52
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare Commercial |
$67.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare VA CCN |
$44.10
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
5109920201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$113.52 |
| Rate for Payer: Aetna of VT Commercial |
$100.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$45.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$50.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$113.52
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$48.25
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.52
|
| Rate for Payer: Multiplan Commercial |
$99.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare Commercial |
$67.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.10
|
| Rate for Payer: United Healthcare VA CCN |
$44.10
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
9609920201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$195.39 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Aetna of VT Commercial |
$250.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$195.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$195.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$224.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$221.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$211.20
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$211.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$211.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$211.20
|
| Rate for Payer: Multiplan Commercial |
$245.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$224.40
|
| Rate for Payer: United Healthcare Commercial |
$250.80
|
|
|
OFFICE/OP NEW SF MDM 15-29 MIN
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
5109920201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Aetna of VT Commercial |
$101.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$95.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$47.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$95.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$64.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$90.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$86.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$48.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$85.06
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$85.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$85.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$85.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$48.15
|
| Rate for Payer: Multiplan Commercial |
$99.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$90.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$48.15
|
| Rate for Payer: United Healthcare Commercial |
$101.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.15
|
| Rate for Payer: United Healthcare VA CCN |
$48.15
|
|
|
OFF/OP CNSLTJ NEW/EST MOD 40
|
Facility
|
OP
|
$691.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
9609924401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$306.04 |
| Max. Negotiated Rate |
$656.45 |
| Rate for Payer: Aetna of VT Commercial |
$656.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$619.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$306.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$619.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$415.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$587.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$559.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$310.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$549.35
|
| Rate for Payer: Cash Price |
$345.50
|
| Rate for Payer: Cigna Commercial |
$552.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$552.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$552.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$310.95
|
| Rate for Payer: Multiplan Commercial |
$642.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$587.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$310.95
|
| Rate for Payer: United Healthcare Commercial |
$656.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.95
|
| Rate for Payer: United Healthcare VA CCN |
$310.95
|
|
|
OFF/OP CNSLTJ NEW/EST MOD 40
|
Facility
|
IP
|
$691.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
9609924401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$511.41 |
| Max. Negotiated Rate |
$656.45 |
| Rate for Payer: Aetna of VT Commercial |
$656.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$511.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$511.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$587.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$580.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$552.80
|
| Rate for Payer: Cash Price |
$345.50
|
| Rate for Payer: Cigna Commercial |
$552.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$552.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$552.80
|
| Rate for Payer: Multiplan Commercial |
$642.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$587.35
|
| Rate for Payer: United Healthcare Commercial |
$656.45
|
|
|
OFF/OP CNSLTJ NEW/EST MOD 40
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
9609924402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$132.75 |
| Max. Negotiated Rate |
$325.24 |
| Rate for Payer: Aetna of VT Commercial |
$325.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$309.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$309.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$309.49
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$137.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$152.65
|
| Rate for Payer: Multiplan Commercial |
$321.78
|
| Rate for Payer: United Healthcare Commercial |
$294.10
|
| Rate for Payer: United Healthcare VA CCN |
$132.75
|
|
|
OFF/OP CNSLTJ NEW/EST MOD 40
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
9609924402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$153.24 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Aetna of VT Commercial |
$328.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$153.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$208.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$294.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$280.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$155.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$275.07
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$276.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$276.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$276.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.70
|
| Rate for Payer: Multiplan Commercial |
$321.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$155.70
|
| Rate for Payer: United Healthcare Commercial |
$328.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.70
|
| Rate for Payer: United Healthcare VA CCN |
$155.70
|
|
|
OFF/OP CNSLTJ NEW/EST MOD 40
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
5109924401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.75 |
| Max. Negotiated Rate |
$325.24 |
| Rate for Payer: Aetna of VT Commercial |
$325.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$309.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$309.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$309.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$309.49
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$137.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$152.65
|
| Rate for Payer: Multiplan Commercial |
$321.78
|
| Rate for Payer: United Healthcare Commercial |
$294.10
|
| Rate for Payer: United Healthcare VA CCN |
$132.75
|
|
