|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Professional
|
Both
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$126.39 |
| Max. Negotiated Rate |
$618.52 |
| Rate for Payer: Aetna of VT Commercial |
$618.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$269.30
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$230.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$285.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$285.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.29
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare Commercial |
$194.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare VA CCN |
$126.39
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$2,047.32
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
4501315301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$906.76 |
| Max. Negotiated Rate |
$1,944.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,944.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,834.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$906.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,834.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,232.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,658.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$921.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,627.62
|
| Rate for Payer: Cash Price |
$1,023.66
|
| Rate for Payer: Cigna Commercial |
$1,637.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,637.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,637.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$921.29
|
| Rate for Payer: Multiplan Commercial |
$1,904.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$921.29
|
| Rate for Payer: United Healthcare Commercial |
$1,944.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$921.29
|
| Rate for Payer: United Healthcare VA CCN |
$921.29
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Professional
|
Both
|
$2,705.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9601315301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$126.39 |
| Max. Negotiated Rate |
$2,542.70 |
| Rate for Payer: Aetna of VT Commercial |
$2,542.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$269.30
|
| Rate for Payer: Cash Price |
$1,352.50
|
| Rate for Payer: Cash Price |
$1,352.50
|
| Rate for Payer: Cigna Commercial |
$230.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$285.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$285.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.29
|
| Rate for Payer: Multiplan Commercial |
$2,515.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare Commercial |
$194.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare VA CCN |
$126.39
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Professional
|
Both
|
$2,048.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
5101315301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$126.39 |
| Max. Negotiated Rate |
$1,925.12 |
| Rate for Payer: Aetna of VT Commercial |
$1,925.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$269.30
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$230.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$285.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$285.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.29
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare Commercial |
$194.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare VA CCN |
$126.39
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9821315301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$291.43 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$291.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$396.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$532.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$523.11
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$296.10
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare VA CCN |
$296.10
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$2,047.32
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
4501315301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,515.22 |
| Max. Negotiated Rate |
$1,944.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,944.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,515.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,515.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,719.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,637.86
|
| Rate for Payer: Cash Price |
$1,023.66
|
| Rate for Payer: Cigna Commercial |
$1,637.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,637.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,637.86
|
| Rate for Payer: Multiplan Commercial |
$1,904.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.22
|
| Rate for Payer: United Healthcare Commercial |
$1,944.95
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Professional
|
Both
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9821315301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$126.39 |
| Max. Negotiated Rate |
$618.52 |
| Rate for Payer: Aetna of VT Commercial |
$618.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$269.30
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$230.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$285.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$285.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.29
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare Commercial |
$194.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare VA CCN |
$126.39
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$2,705.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9601315301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,198.04 |
| Max. Negotiated Rate |
$2,569.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,569.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,198.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,423.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,628.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,299.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,191.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,217.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,150.47
|
| Rate for Payer: Cash Price |
$1,352.50
|
| Rate for Payer: Cigna Commercial |
$2,164.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,164.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,164.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,217.25
|
| Rate for Payer: Multiplan Commercial |
$2,515.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,299.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,217.25
|
| Rate for Payer: United Healthcare Commercial |
$2,569.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,217.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,217.25
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$2,048.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
5101315301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$907.06 |
| Max. Negotiated Rate |
$1,945.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,945.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$907.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,834.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,232.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,658.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$921.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,628.16
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,638.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$921.60
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$921.60
|
| Rate for Payer: United Healthcare Commercial |
$1,945.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$921.60
|
| Rate for Payer: United Healthcare VA CCN |
$921.60
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$2,048.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
5101315301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,515.72 |
| Max. Negotiated Rate |
$1,945.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,945.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,515.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,515.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,740.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,720.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,638.40
|
| Rate for Payer: Cash Price |
$1,024.00
|
| Rate for Payer: Cigna Commercial |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,638.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,638.40
|
| Rate for Payer: Multiplan Commercial |
$1,904.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,740.80
|
| Rate for Payer: United Healthcare Commercial |
$1,945.60
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9821315301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$486.99 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$552.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$526.40
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$486.99 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$552.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$526.40
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$291.43 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$291.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$396.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$532.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$523.11
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$296.10
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare VA CCN |
$296.10
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9601315302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$486.99 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$552.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$526.40
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
IP
|
$2,705.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9601315301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,001.97 |
| Max. Negotiated Rate |
$2,569.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,569.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,001.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,001.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,299.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,272.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,164.00
|
| Rate for Payer: Cash Price |
$1,352.50
|
| Rate for Payer: Cigna Commercial |
$2,164.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,164.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,164.00
|
| Rate for Payer: Multiplan Commercial |
$2,515.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,299.25
|
| Rate for Payer: United Healthcare Commercial |
$2,569.75
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9811315301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$285.96 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$130.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$176.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$269.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$269.30
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$230.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$285.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$285.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$173.29
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare Commercial |
$194.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.39
|
| Rate for Payer: United Healthcare VA CCN |
$126.39
|
|
|
CMPLX RPR E/N/E/L ADDL 5CM/<
|
Facility
|
OP
|
$658.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
9601315302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$291.43 |
| Max. Negotiated Rate |
$625.10 |
| Rate for Payer: Aetna of VT Commercial |
$625.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$291.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$396.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$559.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$532.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$523.11
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cigna Commercial |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$526.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$526.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$296.10
|
| Rate for Payer: Multiplan Commercial |
$611.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$559.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare Commercial |
$625.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$296.10
|
| Rate for Payer: United Healthcare VA CCN |
$296.10
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
5101313201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$392.99 |
| Max. Negotiated Rate |
$504.45 |
| Rate for Payer: Aetna of VT Commercial |
$504.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$392.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$392.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$446.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$424.80
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$424.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$424.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$424.80
|
| Rate for Payer: Multiplan Commercial |
$493.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$451.35
|
| Rate for Payer: United Healthcare Commercial |
$504.45
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Professional
|
Both
|
$880.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
9821313201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$283.64 |
| Max. Negotiated Rate |
$827.20 |
| Rate for Payer: Aetna of VT Commercial |
$827.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$788.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$292.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$788.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$397.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$729.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$729.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$326.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$729.16
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna Commercial |
$518.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$721.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$721.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$442.96
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$283.64
|
| Rate for Payer: United Healthcare Commercial |
$436.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.64
|
| Rate for Payer: United Healthcare VA CCN |
$283.64
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9821313101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$595.04 |
| Max. Negotiated Rate |
$763.80 |
| Rate for Payer: Aetna of VT Commercial |
$763.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$595.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$595.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$683.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$675.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$643.20
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$643.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$643.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$643.20
|
| Rate for Payer: Multiplan Commercial |
$747.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$683.40
|
| Rate for Payer: United Healthcare Commercial |
$763.80
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
5101313301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$118.42 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of VT Commercial |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$136.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$128.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$136.00
|
| Rate for Payer: United Healthcare Commercial |
$152.00
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
OP
|
$159.49
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
4501313301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$70.64 |
| Max. Negotiated Rate |
$151.52 |
| Rate for Payer: Aetna of VT Commercial |
$151.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$142.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$70.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$142.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$96.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$135.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$126.79
|
| Rate for Payer: Cash Price |
$79.75
|
| Rate for Payer: Cigna Commercial |
$127.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$127.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$127.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$71.77
|
| Rate for Payer: Multiplan Commercial |
$148.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$135.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$71.77
|
| Rate for Payer: United Healthcare Commercial |
$151.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.77
|
| Rate for Payer: United Healthcare VA CCN |
$71.77
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Professional
|
Both
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9811313102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$227.30 |
| Max. Negotiated Rate |
$755.76 |
| Rate for Payer: Aetna of VT Commercial |
$755.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$720.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$234.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$720.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$318.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$521.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$521.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$261.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$521.62
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Cigna Commercial |
$414.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$595.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$595.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$365.42
|
| Rate for Payer: Multiplan Commercial |
$747.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$322.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$227.30
|
| Rate for Payer: United Healthcare Commercial |
$349.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.30
|
| Rate for Payer: United Healthcare VA CCN |
$227.30
|
|
