|
PREV VISIT EST AGE 18-39
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
5109939501
|
|
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
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
5109939601
|
|
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 40-64
|
Professional
|
Both
|
$157.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
5109939601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.68 |
| Max. Negotiated Rate |
$195.57 |
| 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 |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$195.57
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cash Price |
$78.50
|
| Rate for Payer: Cigna Commercial |
$95.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.57
|
| Rate for Payer: Multiplan Commercial |
$146.01
|
| Rate for Payer: United Healthcare Commercial |
$133.45
|
| Rate for Payer: United Healthcare VA CCN |
$91.68
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
5109939601
|
|
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
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$199.75 |
| Max. Negotiated Rate |
$428.45 |
| Rate for Payer: Aetna of VT Commercial |
$428.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$404.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$199.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$404.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$271.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$383.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$202.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$358.55
|
| Rate for Payer: Cash Price |
$225.50
|
| Rate for Payer: Cigna Commercial |
$360.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$360.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$360.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$202.95
|
| Rate for Payer: Multiplan Commercial |
$419.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$383.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$202.95
|
| Rate for Payer: United Healthcare Commercial |
$428.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.95
|
| Rate for Payer: United Healthcare VA CCN |
$202.95
|
|
|
PREV VISIT EST AGE 40-64
|
Professional
|
Both
|
$451.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$91.68 |
| Max. Negotiated Rate |
$423.94 |
| Rate for Payer: Aetna of VT Commercial |
$423.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$404.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$404.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$195.57
|
| Rate for Payer: Cash Price |
$225.50
|
| Rate for Payer: Cash Price |
$225.50
|
| Rate for Payer: Cigna Commercial |
$95.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.57
|
| Rate for Payer: Multiplan Commercial |
$419.43
|
| Rate for Payer: United Healthcare Commercial |
$383.35
|
| Rate for Payer: United Healthcare VA CCN |
$91.68
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$333.79 |
| Max. Negotiated Rate |
$428.45 |
| Rate for Payer: Aetna of VT Commercial |
$428.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$333.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$333.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$383.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$378.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$360.80
|
| Rate for Payer: Cash Price |
$225.50
|
| Rate for Payer: Cigna Commercial |
$360.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$360.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$360.80
|
| Rate for Payer: Multiplan Commercial |
$419.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$383.35
|
| Rate for Payer: United Healthcare Commercial |
$428.45
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$217.59 |
| Max. Negotiated Rate |
$279.30 |
| Rate for Payer: Aetna of VT Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$217.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$217.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$249.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$246.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$235.20
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$235.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$235.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$235.20
|
| Rate for Payer: Multiplan Commercial |
$273.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$249.90
|
| Rate for Payer: United Healthcare Commercial |
$279.30
|
|
|
PREV VISIT EST AGE 40-64
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$130.21 |
| Max. Negotiated Rate |
$279.30 |
| Rate for Payer: Aetna of VT Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$263.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$263.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$249.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$238.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$233.73
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$235.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$235.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$235.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$132.30
|
| Rate for Payer: Multiplan Commercial |
$273.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$249.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$132.30
|
| Rate for Payer: United Healthcare Commercial |
$279.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.30
|
| Rate for Payer: United Healthcare VA CCN |
$132.30
|
|
|
PREV VISIT EST AGE 40-64
|
Professional
|
Both
|
$294.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
9609939602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$91.68 |
| Max. Negotiated Rate |
$276.36 |
| Rate for Payer: Aetna of VT Commercial |
$276.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$263.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$263.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$195.57
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$95.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.57
|
| Rate for Payer: Multiplan Commercial |
$273.42
|
| Rate for Payer: United Healthcare Commercial |
$249.90
|
| Rate for Payer: United Healthcare VA CCN |
$91.68
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
5109939301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.69 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna of VT Commercial |
$188.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$119.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$160.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$89.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.41
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$158.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$89.10
|
| Rate for Payer: Multiplan Commercial |
$184.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$89.10
|
| Rate for Payer: United Healthcare Commercial |
$188.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.10
|
| Rate for Payer: United Healthcare VA CCN |
$89.10
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$196.65 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna of VT Commercial |
$421.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$267.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$377.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$359.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$199.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.98
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$199.80
|
| Rate for Payer: Multiplan Commercial |
$412.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$377.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$199.80
|
| Rate for Payer: United Healthcare Commercial |
$421.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$199.80
|
| Rate for Payer: United Healthcare VA CCN |
$199.80
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
5109939301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.54 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna of VT Commercial |
$188.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$146.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$146.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$166.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$158.40
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$158.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.40
|
| Rate for Payer: Multiplan Commercial |
$184.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.30
|
| Rate for Payer: United Healthcare Commercial |
$188.10
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
OP
|
$247.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$109.40 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Aetna of VT Commercial |
$234.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$221.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$109.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$221.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$148.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$209.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$200.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$111.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$196.37
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$197.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$197.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.15
|
| Rate for Payer: Multiplan Commercial |
$229.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$209.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$111.15
|
| Rate for Payer: United Healthcare Commercial |
$234.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.15
|
| Rate for Payer: United Healthcare VA CCN |
$111.15
|
|
|
PREV VISIT EST AGE 5-11
|
Professional
|
Both
|
$444.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$417.36 |
| Rate for Payer: Aetna of VT Commercial |
$417.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$397.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.39
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cash Price |
$222.00
|
| 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 |
$412.92
|
| Rate for Payer: United Healthcare Commercial |
$377.40
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 5-11
|
Professional
|
Both
|
$198.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
5109939301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$186.12 |
| Rate for Payer: Aetna of VT Commercial |
$186.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.39
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| 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 |
$184.14
|
| Rate for Payer: United Healthcare Commercial |
$168.30
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 5-11
|
Professional
|
Both
|
$247.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.63 |
| Max. Negotiated Rate |
$232.18 |
| Rate for Payer: Aetna of VT Commercial |
$232.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$221.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$221.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.39
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cash Price |
$123.50
|
| 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 |
$229.71
|
| Rate for Payer: United Healthcare Commercial |
$209.95
|
| Rate for Payer: United Healthcare VA CCN |
$71.63
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
IP
|
$247.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$182.80 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Aetna of VT Commercial |
$234.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$182.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$182.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$209.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$207.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$197.60
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$197.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$197.60
|
| Rate for Payer: Multiplan Commercial |
$229.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$209.95
|
| Rate for Payer: United Healthcare Commercial |
$234.65
|
|
|
PREV VISIT EST AGE 5-11
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
9609939301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$328.60 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna of VT Commercial |
$421.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$377.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$372.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$355.20
|
| Rate for Payer: Cash Price |
$222.00
|
| Rate for Payer: Cigna Commercial |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.20
|
| Rate for Payer: Multiplan Commercial |
$412.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$377.40
|
| Rate for Payer: United Healthcare Commercial |
$421.80
|
|
|
PREV VISIT NEW AGE 40-64
|
Facility
|
OP
|
$514.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
9609938601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$227.65 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Aetna of VT Commercial |
$488.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$227.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$460.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$309.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$436.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$416.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$231.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$408.63
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cigna Commercial |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$231.30
|
| Rate for Payer: Multiplan Commercial |
$478.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$436.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$231.30
|
| Rate for Payer: United Healthcare Commercial |
$488.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.30
|
| Rate for Payer: United Healthcare VA CCN |
$231.30
|
|
|
PREV VISIT NEW AGE 40-64
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
5109938601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.62 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Aetna of VT Commercial |
$164.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$76.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$104.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$137.53
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$138.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$138.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$138.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$77.85
|
| Rate for Payer: Multiplan Commercial |
$160.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$77.85
|
| Rate for Payer: United Healthcare Commercial |
$164.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.85
|
| Rate for Payer: United Healthcare VA CCN |
$77.85
|
|
|
PREV VISIT NEW AGE 40-64
|
Facility
|
IP
|
$514.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
9609938601
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$380.41 |
| Max. Negotiated Rate |
$488.30 |
| Rate for Payer: Aetna of VT Commercial |
$488.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$380.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$380.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$436.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$431.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.20
|
| Rate for Payer: Cash Price |
$257.00
|
| Rate for Payer: Cigna Commercial |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.20
|
| Rate for Payer: Multiplan Commercial |
$478.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$436.90
|
| Rate for Payer: United Healthcare Commercial |
$488.30
|
|
|
PREV VISIT NEW AGE 40-64
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
9609938602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$151.47 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna of VT Commercial |
$324.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$151.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$205.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$290.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$277.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$153.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$271.89
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$273.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$273.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$153.90
|
| Rate for Payer: Multiplan Commercial |
$318.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$290.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$153.90
|
| Rate for Payer: United Healthcare Commercial |
$324.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$153.90
|
| Rate for Payer: United Healthcare VA CCN |
$153.90
|
|
|
PREV VISIT NEW AGE 40-64
|
Professional
|
Both
|
$342.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
9609938602
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$111.74 |
| Max. Negotiated Rate |
$321.48 |
| Rate for Payer: Aetna of VT Commercial |
$321.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$254.10
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$230.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$230.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.45
|
| Rate for Payer: Multiplan Commercial |
$318.06
|
| Rate for Payer: United Healthcare Commercial |
$290.70
|
| Rate for Payer: United Healthcare VA CCN |
$111.74
|
|
|
PREV VISIT NEW AGE 40-64
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 99386
|
| Hospital Charge Code |
5109938601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$111.74 |
| Max. Negotiated Rate |
$254.10 |
| Rate for Payer: Aetna of VT Commercial |
$162.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$254.10
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$230.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$230.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.45
|
| Rate for Payer: Multiplan Commercial |
$160.89
|
| Rate for Payer: United Healthcare Commercial |
$147.05
|
| Rate for Payer: United Healthcare VA CCN |
$111.74
|
|
