|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
IP
|
$1,073.71
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
4501201701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.65 |
| Max. Negotiated Rate |
$1,020.02 |
| Rate for Payer: Aetna of VT Commercial |
$1,020.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$794.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$794.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$912.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$901.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$858.97
|
| Rate for Payer: Cash Price |
$536.86
|
| Rate for Payer: Cigna Commercial |
$858.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$858.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$858.97
|
| Rate for Payer: Multiplan Commercial |
$998.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$912.65
|
| Rate for Payer: United Healthcare Commercial |
$1,020.02
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
9811201702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$350.78 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Aetna of VT Commercial |
$752.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$350.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$476.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$356.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$629.64
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$356.40
|
| Rate for Payer: Multiplan Commercial |
$736.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$356.40
|
| Rate for Payer: United Healthcare Commercial |
$752.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$356.40
|
| Rate for Payer: United Healthcare VA CCN |
$356.40
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Professional
|
Both
|
$792.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
9811201701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$138.17 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna of VT Commercial |
$744.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$142.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$193.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$354.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$158.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$354.70
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$253.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$236.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$236.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$138.17
|
| Rate for Payer: Multiplan Commercial |
$736.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$196.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$138.18
|
| Rate for Payer: United Healthcare Commercial |
$212.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$138.18
|
| Rate for Payer: United Healthcare VA CCN |
$138.18
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
OP
|
$1,073.71
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
4501201701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$475.55 |
| Max. Negotiated Rate |
$1,020.02 |
| Rate for Payer: Aetna of VT Commercial |
$1,020.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$961.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$475.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$961.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$646.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$912.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$869.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$483.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$853.60
|
| Rate for Payer: Cash Price |
$536.86
|
| Rate for Payer: Cigna Commercial |
$858.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$858.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$858.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$483.17
|
| Rate for Payer: Multiplan Commercial |
$998.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$912.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$483.17
|
| Rate for Payer: United Healthcare Commercial |
$1,020.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$483.17
|
| Rate for Payer: United Healthcare VA CCN |
$483.17
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
9811201702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$586.16 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Aetna of VT Commercial |
$752.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$586.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$586.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$665.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$633.60
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.60
|
| Rate for Payer: Multiplan Commercial |
$736.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.20
|
| Rate for Payer: United Healthcare Commercial |
$752.40
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
9811201701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$586.16 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Aetna of VT Commercial |
$752.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$586.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$586.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$665.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$633.60
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.60
|
| Rate for Payer: Multiplan Commercial |
$736.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.20
|
| Rate for Payer: United Healthcare Commercial |
$752.40
|
|
|
RPR F/E/E/N/L/M 20.1CM-30.0 CM
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
9811201701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$350.78 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Aetna of VT Commercial |
$752.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$350.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$709.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$476.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$356.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$629.64
|
| Rate for Payer: Cash Price |
$396.00
|
| Rate for Payer: Cigna Commercial |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$356.40
|
| Rate for Payer: Multiplan Commercial |
$736.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$356.40
|
| Rate for Payer: United Healthcare Commercial |
$752.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$356.40
|
| Rate for Payer: United Healthcare VA CCN |
$356.40
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Professional
|
Both
|
$417.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
5101201101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$391.98 |
| Rate for Payer: Aetna of VT Commercial |
$391.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$373.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$373.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.40
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$92.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.26
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare Commercial |
$77.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare VA CCN |
$50.66
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$97.44 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$97.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$174.90
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare VA CCN |
$99.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$162.82 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$176.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Professional
|
Both
|
$636.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$597.84 |
| Rate for Payer: Aetna of VT Commercial |
$597.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$569.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$569.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.40
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$92.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.26
|
| Rate for Payer: Multiplan Commercial |
$591.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare Commercial |
$77.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare VA CCN |
$50.66
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$97.44 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$97.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$174.90
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare VA CCN |
$99.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
5101201101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$184.69 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna of VT Commercial |
$396.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$373.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$184.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$373.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$251.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$337.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$187.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.51
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.65
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$187.65
|
| Rate for Payer: United Healthcare Commercial |
$396.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$187.65
|
| Rate for Payer: United Healthcare VA CCN |
$187.65
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$416.70
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
4501201101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$184.56 |
| Max. Negotiated Rate |
$395.87 |
| Rate for Payer: Aetna of VT Commercial |
$395.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$373.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$184.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$373.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$250.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$337.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$187.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.28
|
| Rate for Payer: Cash Price |
$208.35
|
| Rate for Payer: Cigna Commercial |
$333.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.51
|
| Rate for Payer: Multiplan Commercial |
$387.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$187.51
|
| Rate for Payer: United Healthcare Commercial |
$395.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$187.51
|
| Rate for Payer: United Healthcare VA CCN |
$187.51
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$470.70 |
| Max. Negotiated Rate |
$604.20 |
| Rate for Payer: Aetna of VT Commercial |
$604.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$470.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$470.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$540.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$508.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$508.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$508.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$508.80
|
| Rate for Payer: Multiplan Commercial |
$591.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$540.60
|
| Rate for Payer: United Healthcare Commercial |
$604.20
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201101
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$604.20 |
| Rate for Payer: Aetna of VT Commercial |
$604.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$569.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$281.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$569.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$382.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$540.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$515.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$505.62
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$508.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$508.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$508.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$286.20
|
| Rate for Payer: Multiplan Commercial |
$591.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$540.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$286.20
|
| Rate for Payer: United Healthcare Commercial |
$604.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$286.20
|
| Rate for Payer: United Healthcare VA CCN |
$286.20
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$162.82 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$176.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$97.44 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$97.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$174.90
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$99.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.00
|
| Rate for Payer: United Healthcare VA CCN |
$99.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$241.40 |
| Rate for Payer: Aetna of VT Commercial |
$206.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.40
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$92.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.26
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare Commercial |
$77.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare VA CCN |
$50.66
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
5101201101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$308.62 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna of VT Commercial |
$396.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$308.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$308.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$350.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$333.60
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.60
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.45
|
| Rate for Payer: United Healthcare Commercial |
$396.15
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$416.70
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
4501201101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$308.40 |
| Max. Negotiated Rate |
$395.87 |
| Rate for Payer: Aetna of VT Commercial |
$395.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$308.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$308.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$350.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$333.36
|
| Rate for Payer: Cash Price |
$208.35
|
| Rate for Payer: Cigna Commercial |
$333.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.36
|
| Rate for Payer: Multiplan Commercial |
$387.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.19
|
| Rate for Payer: United Healthcare Commercial |
$395.87
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$162.82 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of VT Commercial |
$209.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$162.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$187.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$176.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$176.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$176.00
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: United Healthcare Commercial |
$209.00
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9811201102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$241.40 |
| Rate for Payer: Aetna of VT Commercial |
$206.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.40
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$92.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.26
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare Commercial |
$77.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare VA CCN |
$50.66
|
|
|
RPR F/E/E/N/L/M 2.5CM/<
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
9601201102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$241.40 |
| Rate for Payer: Aetna of VT Commercial |
$206.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$197.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$241.40
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$92.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$173.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$173.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.26
|
| Rate for Payer: Multiplan Commercial |
$204.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare Commercial |
$77.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.66
|
| Rate for Payer: United Healthcare VA CCN |
$50.66
|
|
|
RPR F/E/E/N/L/M 2.6CM-5.0 CM
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
9811201301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$52.16 |
| Max. Negotiated Rate |
$264.30 |
| Rate for Payer: Aetna of VT Commercial |
$251.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$240.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$240.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$73.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$264.30
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cigna Commercial |
$96.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.33
|
| Rate for Payer: Multiplan Commercial |
$249.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$52.16
|
| Rate for Payer: United Healthcare Commercial |
$80.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.16
|
| Rate for Payer: United Healthcare VA CCN |
$52.16
|
|
