|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9811313102
|
|
Hospital Revenue Code
|
981
|
| 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
|
OP
|
$880.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
9811313201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$389.75 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna of VT Commercial |
$836.00
|
| 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 |
$389.75
|
| 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 |
$529.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$748.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$712.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$396.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$699.60
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna Commercial |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$396.00
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$748.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$836.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare VA CCN |
$396.00
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
OP
|
$352.34
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
4501313101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$156.05 |
| Max. Negotiated Rate |
$334.72 |
| Rate for Payer: Aetna of VT Commercial |
$334.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$315.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$156.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$315.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$212.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$299.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$285.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$158.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$280.11
|
| Rate for Payer: Cash Price |
$176.17
|
| Rate for Payer: Cigna Commercial |
$281.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$281.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$281.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$158.55
|
| Rate for Payer: Multiplan Commercial |
$327.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$299.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$158.55
|
| Rate for Payer: United Healthcare Commercial |
$334.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$158.55
|
| Rate for Payer: United Healthcare VA CCN |
$158.55
|
|
|
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
|
Facility
|
IP
|
$530.96
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
4501313201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$392.96 |
| Max. Negotiated Rate |
$504.41 |
| Rate for Payer: Aetna of VT Commercial |
$504.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$392.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$392.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$446.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$424.77
|
| Rate for Payer: Cash Price |
$265.48
|
| Rate for Payer: Cigna Commercial |
$424.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$424.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$424.77
|
| Rate for Payer: Multiplan Commercial |
$493.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$451.32
|
| Rate for Payer: United Healthcare Commercial |
$504.41
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$522.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
9601313302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$386.33 |
| Max. Negotiated Rate |
$495.90 |
| Rate for Payer: Aetna of VT Commercial |
$495.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$443.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$438.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$417.60
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$417.60
|
| Rate for Payer: Multiplan Commercial |
$485.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$443.70
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
OP
|
$880.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
9811313202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$389.75 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna of VT Commercial |
$836.00
|
| 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 |
$389.75
|
| 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 |
$529.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$748.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$712.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$396.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$699.60
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna Commercial |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$396.00
|
| Rate for Payer: Multiplan Commercial |
$818.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$748.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$836.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$396.00
|
| Rate for Payer: United Healthcare VA CCN |
$396.00
|
|
|
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
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9811313101
|
|
Hospital Revenue Code
|
981
|
| 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
|
Professional
|
Both
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9811313101
|
|
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
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Professional
|
Both
|
$880.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
9811313201
|
|
Hospital Revenue Code
|
981
|
| 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
|
Professional
|
Both
|
$1,411.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
9601313201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$283.64 |
| Max. Negotiated Rate |
$1,326.34 |
| Rate for Payer: Aetna of VT Commercial |
$1,326.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,264.11
|
| 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 |
$1,264.11
|
| 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 |
$705.50
|
| Rate for Payer: Cash Price |
$705.50
|
| 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 |
$1,312.23
|
| 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
|
Professional
|
Both
|
$522.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
9811313302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$116.00 |
| Max. Negotiated Rate |
$490.68 |
| Rate for Payer: Aetna of VT Commercial |
$490.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$467.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$119.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$467.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$162.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$239.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$239.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$133.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$239.28
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$212.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.75
|
| Rate for Payer: Multiplan Commercial |
$485.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$116.00
|
| Rate for Payer: United Healthcare Commercial |
$178.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.00
|
| Rate for Payer: United Healthcare VA CCN |
$116.00
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
5101313201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$283.64 |
| Max. Negotiated Rate |
$729.16 |
| Rate for Payer: Aetna of VT Commercial |
$499.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$475.72
|
| 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 |
$475.72
|
| 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 |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| 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 |
$493.83
|
| 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
|
$522.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
9811313301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$386.33 |
| Max. Negotiated Rate |
$495.90 |
| Rate for Payer: Aetna of VT Commercial |
$495.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$443.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$438.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$417.60
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$417.60
|
| Rate for Payer: Multiplan Commercial |
$485.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$443.70
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
OP
|
$522.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
9821313301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$495.90 |
| Rate for Payer: Aetna of VT Commercial |
$495.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$467.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$231.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$467.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$314.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$443.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$422.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$234.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$414.99
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$417.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$234.90
|
| Rate for Payer: Multiplan Commercial |
$485.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$443.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$234.90
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$234.90
|
| Rate for Payer: United Healthcare VA CCN |
$234.90
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
5101313201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$235.18 |
| 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 |
$475.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$235.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$475.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$319.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$451.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$430.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$422.14
|
| 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: Martins Point Health Care Commercial |
$238.95
|
| Rate for Payer: Multiplan Commercial |
$493.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$451.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$238.95
|
| Rate for Payer: United Healthcare Commercial |
$504.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$238.95
|
| Rate for Payer: United Healthcare VA CCN |
$238.95
|
|
|
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
|
Facility
|
OP
|
$804.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
9811313102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$356.09 |
| 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 |
$720.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$356.09
|
| 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 |
$484.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$683.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$651.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$361.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$639.18
|
| 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: Martins Point Health Care Commercial |
$361.80
|
| Rate for Payer: Multiplan Commercial |
$747.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$683.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$361.80
|
| Rate for Payer: United Healthcare Commercial |
$763.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$361.80
|
| Rate for Payer: United Healthcare VA CCN |
$361.80
|
|
|
CMPLX RPR F/C/C/M/N/AX/G/H/F
|
Facility
|
IP
|
$522.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
9821313301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$386.33 |
| Max. Negotiated Rate |
$495.90 |
| Rate for Payer: Aetna of VT Commercial |
$495.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$386.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$443.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$438.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$417.60
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$417.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$417.60
|
| Rate for Payer: Multiplan Commercial |
$485.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$443.70
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
|
|
CMPLX RPR S/A/L 1.1-2.5 CM
|
Facility
|
IP
|
$672.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
9811312001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$497.35 |
| Max. Negotiated Rate |
$638.40 |
| Rate for Payer: Aetna of VT Commercial |
$638.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$497.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$497.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$571.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$564.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$537.60
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$537.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$537.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$537.60
|
| Rate for Payer: Multiplan Commercial |
$624.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$571.20
|
| Rate for Payer: United Healthcare Commercial |
$638.40
|
|
|
CMPLX RPR S/A/L 1.1-2.5 CM
|
Professional
|
Both
|
$672.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
9811312002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$217.18 |
| Max. Negotiated Rate |
$631.68 |
| Rate for Payer: Aetna of VT Commercial |
$631.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$223.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$304.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$477.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$477.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$249.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$477.29
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$398.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$543.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$543.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$334.09
|
| Rate for Payer: Multiplan Commercial |
$624.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$308.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$217.18
|
| Rate for Payer: United Healthcare Commercial |
$334.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$217.18
|
| Rate for Payer: United Healthcare VA CCN |
$217.18
|
|
|
CMPLX RPR S/A/L 1.1-2.5 CM
|
Professional
|
Both
|
$672.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
9821312001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$217.18 |
| Max. Negotiated Rate |
$631.68 |
| Rate for Payer: Aetna of VT Commercial |
$631.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$223.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$304.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$477.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$477.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$249.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$477.29
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$398.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$543.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$543.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$334.09
|
| Rate for Payer: Multiplan Commercial |
$624.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$308.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$217.18
|
| Rate for Payer: United Healthcare Commercial |
$334.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$217.18
|
| Rate for Payer: United Healthcare VA CCN |
$217.18
|
|
|
CMPLX RPR S/A/L 1.1-2.5 CM
|
Facility
|
IP
|
$458.45
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
4501312001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$339.30 |
| Max. Negotiated Rate |
$435.53 |
| Rate for Payer: Aetna of VT Commercial |
$435.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$339.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$339.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$389.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$385.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$366.76
|
| Rate for Payer: Cash Price |
$229.22
|
| Rate for Payer: Cigna Commercial |
$366.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$366.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$366.76
|
| Rate for Payer: Multiplan Commercial |
$426.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$389.68
|
| Rate for Payer: United Healthcare Commercial |
$435.53
|
|
|
CMPLX RPR S/A/L 1.1-2.5 CM
|
Facility
|
OP
|
$672.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
9811312001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$297.63 |
| Max. Negotiated Rate |
$638.40 |
| Rate for Payer: Aetna of VT Commercial |
$638.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$297.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$602.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$404.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$571.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$544.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$302.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$534.24
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$537.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$537.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$537.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$302.40
|
| Rate for Payer: Multiplan Commercial |
$624.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$571.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$638.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$302.40
|
| Rate for Payer: United Healthcare VA CCN |
$302.40
|
|
