|
PER PM REEVAL EST PAT 65+ YR
|
Professional
|
Both
|
$157.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
5109939701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$215.55 |
| Rate for Payer: Aetna of VT Commercial |
$147.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$140.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$140.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$215.55
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cigna Commercial |
$100.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.90
|
| Rate for Payer: Multiplan Commercial |
$146.01
|
| Rate for Payer: United Healthcare Commercial |
$133.45
|
| Rate for Payer: United Healthcare VA CCN |
$96.46
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
5109939701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.54 |
| Max. Negotiated Rate |
$149.15 |
| Rate for Payer: Aetna of VT Commercial |
$149.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$140.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$140.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$94.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$133.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$127.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$70.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$124.81
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cigna Commercial |
$125.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$125.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$125.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.65
|
| Rate for Payer: Multiplan Commercial |
$146.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$133.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$70.65
|
| Rate for Payer: United Healthcare Commercial |
$149.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.65
|
| Rate for Payer: United Healthcare VA CCN |
$70.65
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
9609939702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna of VT Commercial |
$288.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$134.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$272.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$183.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$246.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.68
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$243.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$136.80
|
| Rate for Payer: Multiplan Commercial |
$282.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$136.80
|
| Rate for Payer: United Healthcare Commercial |
$288.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$136.80
|
| Rate for Payer: United Healthcare VA CCN |
$136.80
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
9609939701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$204.18 |
| Max. Negotiated Rate |
$437.95 |
| Rate for Payer: Aetna of VT Commercial |
$437.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$413.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$204.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$413.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$277.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$373.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$207.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$366.50
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$368.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$368.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$368.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$207.45
|
| Rate for Payer: Multiplan Commercial |
$428.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$391.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.45
|
| Rate for Payer: United Healthcare Commercial |
$437.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.45
|
| Rate for Payer: United Healthcare VA CCN |
$207.45
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
9609939701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$341.19 |
| Max. Negotiated Rate |
$437.95 |
| Rate for Payer: Aetna of VT Commercial |
$437.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$341.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$341.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$391.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$387.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$368.80
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$368.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$368.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$368.80
|
| Rate for Payer: Multiplan Commercial |
$428.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$391.85
|
| Rate for Payer: United Healthcare Commercial |
$437.95
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
9609939701
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$433.34 |
| Rate for Payer: Aetna of VT Commercial |
$433.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$413.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$413.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$215.55
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$100.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.90
|
| Rate for Payer: Multiplan Commercial |
$428.73
|
| Rate for Payer: United Healthcare Commercial |
$391.85
|
| Rate for Payer: United Healthcare VA CCN |
$96.46
|
|
|
PER PM REEVAL EST PAT 65+ YR
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
9609939702
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$224.99 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna of VT Commercial |
$288.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$224.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$224.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$255.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$243.20
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$243.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$243.20
|
| Rate for Payer: Multiplan Commercial |
$282.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$258.40
|
| Rate for Payer: United Healthcare Commercial |
$288.80
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$212.41 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna of VT Commercial |
$272.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$212.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$212.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$229.60
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$229.60
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$243.95
|
| Rate for Payer: United Healthcare Commercial |
$272.65
|
|
|
PER PM REEVAL EST PAT INFANT
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
5109939101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$65.90 |
| Max. Negotiated Rate |
$269.78 |
| Rate for Payer: Aetna of VT Commercial |
$269.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.43
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$68.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$151.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$151.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.67
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: United Healthcare Commercial |
$243.95
|
| Rate for Payer: United Healthcare VA CCN |
$65.90
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$39.42 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$53.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$70.75
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.05
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare VA CCN |
$40.05
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
5109939101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$127.11 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna of VT Commercial |
$272.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$172.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$232.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$129.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$228.16
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$229.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$129.15
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$243.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$129.15
|
| Rate for Payer: United Healthcare Commercial |
$272.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$129.15
|
| Rate for Payer: United Healthcare VA CCN |
$129.15
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
5109939101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$212.41 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna of VT Commercial |
$272.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$212.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$212.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$229.60
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$229.60
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$243.95
|
| Rate for Payer: United Healthcare Commercial |
$272.65
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$127.11 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna of VT Commercial |
$272.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$172.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$243.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$232.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$129.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$228.16
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$229.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$229.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$129.15
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$243.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$129.15
|
| Rate for Payer: United Healthcare Commercial |
$272.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$129.15
|
| Rate for Payer: United Healthcare VA CCN |
$129.15
|
|
|
PER PM REEVAL EST PAT INFANT
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$65.90 |
| Max. Negotiated Rate |
$269.78 |
| Rate for Payer: Aetna of VT Commercial |
$269.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.43
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$68.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$151.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$151.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.67
|
| Rate for Payer: Multiplan Commercial |
$266.91
|
| Rate for Payer: United Healthcare Commercial |
$243.95
|
| Rate for Payer: United Healthcare VA CCN |
$65.90
|
|
|
PER PM REEVAL EST PAT INFANT
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$65.90 |
| Max. Negotiated Rate |
$155.43 |
| Rate for Payer: Aetna of VT Commercial |
$83.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$155.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.43
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$68.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$151.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$151.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.67
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: United Healthcare Commercial |
$75.65
|
| Rate for Payer: United Healthcare VA CCN |
$65.90
|
|
|
PER PM REEVAL EST PAT INFANT
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
9609939102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$65.87 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$74.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$71.20
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
IP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281 RT
|
| Hospital Charge Code |
32019281RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3,018.20 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.48
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
IP
|
$929.57
|
|
|
Service Code
|
CPT 19281
|
| Hospital Charge Code |
3201928101
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$687.97 |
| Max. Negotiated Rate |
$883.09 |
| Rate for Payer: Aetna of VT Commercial |
$883.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$687.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$687.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$790.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$780.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$743.66
|
| Rate for Payer: Cash Price |
$464.79
|
| Rate for Payer: Cigna Commercial |
$743.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$743.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$743.66
|
| Rate for Payer: Multiplan Commercial |
$864.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$790.13
|
| Rate for Payer: United Healthcare Commercial |
$883.09
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
OP
|
$929.57
|
|
|
Service Code
|
CPT 19281
|
| Hospital Charge Code |
3201928101
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$411.71 |
| Max. Negotiated Rate |
$883.09 |
| Rate for Payer: Aetna of VT Commercial |
$883.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$832.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$411.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$832.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$559.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$790.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$752.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$418.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$739.01
|
| Rate for Payer: Cash Price |
$464.79
|
| Rate for Payer: Cigna Commercial |
$743.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$743.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$743.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$418.31
|
| Rate for Payer: Multiplan Commercial |
$864.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$790.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$418.31
|
| Rate for Payer: United Healthcare Commercial |
$883.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$418.31
|
| Rate for Payer: United Healthcare VA CCN |
$418.31
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
OP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281 LT
|
| Hospital Charge Code |
32019281LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,806.19 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,455.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,242.09
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.14
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.14
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
IP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281 LT
|
| Hospital Charge Code |
32019281LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3,018.20 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.48
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
|
|
PERQ DEVICE BREAST 1ST IMAG
|
Facility
|
OP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281 RT
|
| Hospital Charge Code |
32019281RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,806.19 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,455.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,242.09
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.14
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.14
|
|
|
PERQ DEVICE BREAST EA IMAG
|
Facility
|
IP
|
$1,481.98
|
|
|
Service Code
|
CPT 19282
|
| Hospital Charge Code |
3201928201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,096.81 |
| Max. Negotiated Rate |
$1,407.88 |
| Rate for Payer: Aetna of VT Commercial |
$1,407.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,096.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,096.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,259.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,244.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,185.58
|
| Rate for Payer: Cash Price |
$740.99
|
| Rate for Payer: Cigna Commercial |
$1,185.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,185.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,185.58
|
| Rate for Payer: Multiplan Commercial |
$1,378.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,259.68
|
| Rate for Payer: United Healthcare Commercial |
$1,407.88
|
|
|
PERQ DEVICE BREAST EA IMAG
|
Facility
|
OP
|
$1,481.98
|
|
|
Service Code
|
CPT 19282
|
| Hospital Charge Code |
3201928201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$656.37 |
| Max. Negotiated Rate |
$1,407.88 |
| Rate for Payer: Aetna of VT Commercial |
$1,407.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,327.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$656.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,327.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$892.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,259.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,200.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$666.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,178.17
|
| Rate for Payer: Cash Price |
$740.99
|
| Rate for Payer: Cigna Commercial |
$1,185.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,185.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,185.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$666.89
|
| Rate for Payer: Multiplan Commercial |
$1,378.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,259.68
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$666.89
|
| Rate for Payer: United Healthcare Commercial |
$1,407.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$666.89
|
| Rate for Payer: United Healthcare VA CCN |
$666.89
|
|
|
PERQ DEVICE BREAST EA IMAG
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
CPT 19282 26
|
| Hospital Charge Code |
9721928201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$314.54 |
| Max. Negotiated Rate |
$403.75 |
| Rate for Payer: Aetna of VT Commercial |
$403.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$314.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$314.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$361.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$340.00
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$340.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$340.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$340.00
|
| Rate for Payer: Multiplan Commercial |
$395.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$361.25
|
| Rate for Payer: United Healthcare Commercial |
$403.75
|
|
