|
PPPS, SUBSEQ VISIT
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043901
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna of VT Commercial |
$226.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$202.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$199.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$190.40
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.30
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
IP
|
$2,044.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
9830043901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$1,512.76 |
| Max. Negotiated Rate |
$1,941.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,941.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,512.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,512.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,737.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,716.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,635.20
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cigna Commercial |
$1,635.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,635.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,635.20
|
| Rate for Payer: Multiplan Commercial |
$1,900.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,737.40
|
| Rate for Payer: United Healthcare Commercial |
$1,941.80
|
|
|
PPPS, SUBSEQ VISIT
|
Professional
|
Both
|
$2,044.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
9830043901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$124.02 |
| Max. Negotiated Rate |
$1,921.36 |
| Rate for Payer: Aetna of VT Commercial |
$1,921.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,831.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,831.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$173.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.38
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$1,900.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare Commercial |
$190.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare VA CCN |
$124.03
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
OP
|
$2,044.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
9830043901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$905.29 |
| Max. Negotiated Rate |
$1,941.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,941.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,831.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$905.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,831.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,230.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,737.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,655.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$919.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,624.98
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cigna Commercial |
$1,635.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,635.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,635.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$919.80
|
| Rate for Payer: Multiplan Commercial |
$1,900.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,737.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$919.80
|
| Rate for Payer: United Healthcare Commercial |
$1,941.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$919.80
|
| Rate for Payer: United Healthcare VA CCN |
$919.80
|
|
|
PPPS, SUBSEQ VISIT
|
Professional
|
Both
|
$143.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043902
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$124.02 |
| Max. Negotiated Rate |
$201.10 |
| Rate for Payer: Aetna of VT Commercial |
$134.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$173.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.38
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare Commercial |
$190.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare VA CCN |
$124.03
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043902
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$63.33 |
| Max. Negotiated Rate |
$135.85 |
| Rate for Payer: Aetna of VT Commercial |
$135.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$121.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$115.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$64.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$113.69
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$114.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$114.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$114.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$64.35
|
| Rate for Payer: Multiplan Commercial |
$132.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$121.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$64.35
|
| Rate for Payer: United Healthcare Commercial |
$135.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$64.35
|
| Rate for Payer: United Healthcare VA CCN |
$64.35
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043902
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$105.83 |
| Max. Negotiated Rate |
$135.85 |
| Rate for Payer: Aetna of VT Commercial |
$135.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$121.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$120.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$114.40
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$114.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$114.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$114.40
|
| Rate for Payer: Multiplan Commercial |
$132.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$121.55
|
| Rate for Payer: United Healthcare Commercial |
$135.85
|
|
|
PPPS, SUBSEQ VISIT
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
5100043901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.11 |
| Max. Negotiated Rate |
$201.10 |
| Rate for Payer: Aetna of VT Commercial |
$89.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$173.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.38
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$88.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare Commercial |
$190.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare VA CCN |
$124.03
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
5100043901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.08 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna of VT Commercial |
$90.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$42.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$57.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$75.53
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$88.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$42.75
|
| Rate for Payer: United Healthcare Commercial |
$90.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.75
|
| Rate for Payer: United Healthcare VA CCN |
$42.75
|
|
|
PRAMIPEXOLE .5 MG
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 5723718290
|
| Hospital Charge Code |
2500000564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
PRAMIPEXOLE .5 MG
|
Facility
|
IP
|
$0.01
|
|
| Hospital Charge Code |
2500000564
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
PRAMIPEXOLE .5 MG
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
2500000564
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
PRAMIPEXOLE .5 MG
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5723718290
|
| Hospital Charge Code |
2500000564
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
PRESSURE PAD 33X68 AIR ONE
|
Facility
|
IP
|
$276.82
|
|
| Hospital Charge Code |
2700030731
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$204.87 |
| Max. Negotiated Rate |
$262.98 |
| Rate for Payer: Aetna of VT Commercial |
$262.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$204.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$204.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$235.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$232.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$221.46
|
| Rate for Payer: Cash Price |
$138.41
|
| Rate for Payer: Cigna Commercial |
$221.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$221.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$221.46
|
| Rate for Payer: Multiplan Commercial |
$257.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$235.30
|
| Rate for Payer: United Healthcare Commercial |
$262.98
|
|
|
PRESSURE PAD 33X68 AIR ONE
|
Facility
|
OP
|
$276.82
|
|
| Hospital Charge Code |
2700030731
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$122.60 |
| Max. Negotiated Rate |
$262.98 |
| Rate for Payer: Aetna of VT Commercial |
$262.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$248.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$122.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$248.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$166.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$235.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$224.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$124.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$220.07
|
| Rate for Payer: Cash Price |
$138.41
|
| Rate for Payer: Cigna Commercial |
$221.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$221.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$221.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.57
|
| Rate for Payer: Multiplan Commercial |
$257.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$235.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.57
|
| Rate for Payer: United Healthcare Commercial |
$262.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.57
|
| Rate for Payer: United Healthcare VA CCN |
$124.57
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna of VT Commercial |
$31.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.23
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.85
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.85
|
| Rate for Payer: United Healthcare Commercial |
$31.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.85
|
| Rate for Payer: United Healthcare VA CCN |
$14.85
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$51.81 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Aetna of VT Commercial |
$66.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$51.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$51.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$59.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$56.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$56.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$56.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$56.00
|
| Rate for Payer: Multiplan Commercial |
$65.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$66.50
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Professional
|
Both
|
$33.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$31.02 |
| Rate for Payer: Aetna of VT Commercial |
$31.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.87
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$11.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.56
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare Commercial |
$16.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare VA CCN |
$10.99
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Aetna of VT Commercial |
$66.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$31.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$59.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$55.65
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$56.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$56.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$56.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$65.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$31.50
|
| Rate for Payer: United Healthcare Commercial |
$66.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.50
|
| Rate for Payer: United Healthcare VA CCN |
$31.50
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
5109940601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$35.72 |
| Rate for Payer: Aetna of VT Commercial |
$35.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$34.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$34.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.87
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$11.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.56
|
| Rate for Payer: Multiplan Commercial |
$35.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare Commercial |
$16.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare VA CCN |
$10.99
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna of VT Commercial |
$31.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.40
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.05
|
| Rate for Payer: United Healthcare Commercial |
$31.35
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
9609940601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$65.80 |
| Rate for Payer: Aetna of VT Commercial |
$65.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$20.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.87
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$11.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.56
|
| Rate for Payer: Multiplan Commercial |
$65.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare Commercial |
$16.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.99
|
| Rate for Payer: United Healthcare VA CCN |
$10.99
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
5109940601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna of VT Commercial |
$36.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$34.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$16.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$34.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$22.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$32.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$30.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.21
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$30.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$30.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.10
|
| Rate for Payer: Multiplan Commercial |
$35.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.10
|
| Rate for Payer: United Healthcare Commercial |
$36.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.10
|
| Rate for Payer: United Healthcare VA CCN |
$17.10
|
|
|
PREVENTIV COUNSL INDIV SPX 45M
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
CPT 99406
|
| Hospital Charge Code |
5109940601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna of VT Commercial |
$36.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$32.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$31.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.40
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$30.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$30.40
|
| Rate for Payer: Multiplan Commercial |
$35.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.30
|
| Rate for Payer: United Healthcare Commercial |
$36.10
|
|
|
PREV VISIT EST AGE 12-17
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$82.13 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna of VT Commercial |
$253.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$181.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$181.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$181.51
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$84.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$175.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$175.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$108.70
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: United Healthcare Commercial |
$229.50
|
| Rate for Payer: United Healthcare VA CCN |
$82.13
|
|
