|
PREV VISIT EST AGE 12-17
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$119.58 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna of VT Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$119.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$229.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$218.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.65
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$121.50
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$229.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$121.50
|
| Rate for Payer: United Healthcare Commercial |
$256.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.50
|
| Rate for Payer: United Healthcare VA CCN |
$121.50
|
|
|
PREV VISIT EST AGE 12-17
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
5109939401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$101.87 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.85
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare VA CCN |
$103.50
|
|
|
PREV VISIT EST AGE 12-17
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939402
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$199.83 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna of VT Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$199.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$199.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$229.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$226.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.00
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$229.50
|
| Rate for Payer: United Healthcare Commercial |
$256.50
|
|
|
PREV VISIT EST AGE 12-17
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$221.45 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$221.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$301.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$405.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$225.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$397.50
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare VA CCN |
$225.00
|
|
|
PREV VISIT EST AGE 12-17
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$82.13 |
| Max. Negotiated Rate |
$470.00 |
| Rate for Payer: Aetna of VT Commercial |
$470.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.95
|
| 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 |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| 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 |
$465.00
|
| Rate for Payer: United Healthcare Commercial |
$425.00
|
| Rate for Payer: United Healthcare VA CCN |
$82.13
|
|
|
PREV VISIT EST AGE 12-17
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
5109939401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.22 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$193.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
|
|
PREV VISIT EST AGE 12-17
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
5109939401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.13 |
| Max. Negotiated Rate |
$216.20 |
| Rate for Payer: Aetna of VT Commercial |
$216.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.06
|
| 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 |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| 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 |
$213.90
|
| Rate for Payer: United Healthcare Commercial |
$195.50
|
| Rate for Payer: United Healthcare VA CCN |
$82.13
|
|
|
PREV VISIT EST AGE 12-17
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
9609939401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$370.05 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna of VT Commercial |
$475.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$425.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$420.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$400.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.00
|
| Rate for Payer: Multiplan Commercial |
$465.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$425.00
|
| Rate for Payer: United Healthcare Commercial |
$475.00
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$59.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$78.70
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.55
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare VA CCN |
$44.55
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
IP
|
$386.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
5109939201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$285.68 |
| Max. Negotiated Rate |
$366.70 |
| Rate for Payer: Aetna of VT Commercial |
$366.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$285.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$285.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$328.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$324.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$308.80
|
| Rate for Payer: Cash Price |
$193.00
|
| Rate for Payer: Cigna Commercial |
$308.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$308.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$308.80
|
| Rate for Payer: Multiplan Commercial |
$358.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$328.10
|
| Rate for Payer: United Healthcare Commercial |
$366.70
|
|
|
PREV VISIT EST AGE 1-4
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9609939201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$165.95 |
| Rate for Payer: Aetna of VT Commercial |
$93.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.95
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$160.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$160.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.64
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: United Healthcare Commercial |
$84.15
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9609939201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.27 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.20
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9609939201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$59.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$78.70
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.55
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare VA CCN |
$44.55
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
OP
|
$386.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
5109939201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.96 |
| Max. Negotiated Rate |
$366.70 |
| Rate for Payer: Aetna of VT Commercial |
$366.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$345.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$170.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$345.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$232.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$328.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$312.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$306.87
|
| Rate for Payer: Cash Price |
$193.00
|
| Rate for Payer: Cigna Commercial |
$308.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$308.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$308.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.70
|
| Rate for Payer: Multiplan Commercial |
$358.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$328.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$173.70
|
| Rate for Payer: United Healthcare Commercial |
$366.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$173.70
|
| Rate for Payer: United Healthcare VA CCN |
$173.70
|
|
|
PREV VISIT EST AGE 1-4
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
9609939202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$165.95 |
| Rate for Payer: Aetna of VT Commercial |
$93.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.95
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$160.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$160.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.64
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: United Healthcare Commercial |
$84.15
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 1-4
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.27 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.20
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
|
|
PREV VISIT EST AGE 1-4
|
Professional
|
Both
|
$386.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
5109939201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$362.84 |
| Rate for Payer: Aetna of VT Commercial |
$362.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$345.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$345.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.95
|
| Rate for Payer: Cash Price |
$193.00
|
| Rate for Payer: Cash Price |
$193.00
|
| Rate for Payer: Cigna Commercial |
$74.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$160.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$160.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.64
|
| Rate for Payer: Multiplan Commercial |
$358.98
|
| Rate for Payer: United Healthcare Commercial |
$328.10
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 18-39
|
Professional
|
Both
|
$432.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.04 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna of VT Commercial |
$406.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.93
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$181.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$181.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.62
|
| Rate for Payer: Multiplan Commercial |
$401.76
|
| Rate for Payer: United Healthcare Commercial |
$367.20
|
| Rate for Payer: United Healthcare VA CCN |
$84.04
|
|
|
PREV VISIT EST AGE 18-39
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$319.72 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna of VT Commercial |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$319.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$319.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$367.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$362.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$345.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$345.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$345.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$345.60
|
| Rate for Payer: Multiplan Commercial |
$401.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$367.20
|
| Rate for Payer: United Healthcare Commercial |
$410.40
|
|
|
PREV VISIT EST AGE 18-39
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$204.27 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna of VT Commercial |
$262.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$204.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$204.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$234.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$231.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$220.80
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$220.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$220.80
|
| Rate for Payer: Multiplan Commercial |
$256.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$234.60
|
| Rate for Payer: United Healthcare Commercial |
$262.20
|
|
|
PREV VISIT EST AGE 18-39
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
5109939501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.20 |
| 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 |
$116.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$133.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$131.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$125.60
|
| 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: Multiplan Commercial |
$146.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$133.45
|
| Rate for Payer: United Healthcare Commercial |
$149.15
|
|
|
PREV VISIT EST AGE 18-39
|
Professional
|
Both
|
$157.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
5109939501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.04 |
| Max. Negotiated Rate |
$185.93 |
| 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 |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.93
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$181.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$181.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.62
|
| Rate for Payer: Multiplan Commercial |
$146.01
|
| Rate for Payer: United Healthcare Commercial |
$133.45
|
| Rate for Payer: United Healthcare VA CCN |
$84.04
|
|
|
PREV VISIT EST AGE 18-39
|
Professional
|
Both
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.04 |
| Max. Negotiated Rate |
$259.44 |
| Rate for Payer: Aetna of VT Commercial |
$259.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$247.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$247.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.93
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$87.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$181.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$181.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.62
|
| Rate for Payer: Multiplan Commercial |
$256.68
|
| Rate for Payer: United Healthcare Commercial |
$234.60
|
| Rate for Payer: United Healthcare VA CCN |
$84.04
|
|
|
PREV VISIT EST AGE 18-39
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$191.33 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna of VT Commercial |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$191.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$260.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$367.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$349.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$194.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$343.44
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$345.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$345.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$345.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$194.40
|
| Rate for Payer: Multiplan Commercial |
$401.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$367.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$194.40
|
| Rate for Payer: United Healthcare Commercial |
$410.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$194.40
|
| Rate for Payer: United Healthcare VA CCN |
$194.40
|
|
|
PREV VISIT EST AGE 18-39
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
9609939502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.24 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna of VT Commercial |
$262.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$247.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$122.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$247.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$166.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$234.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$223.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$124.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$219.42
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$220.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$220.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.20
|
| Rate for Payer: Multiplan Commercial |
$256.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$234.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.20
|
| Rate for Payer: United Healthcare Commercial |
$262.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.20
|
| Rate for Payer: United Healthcare VA CCN |
$124.20
|
|
