|
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
|
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
|
|
|
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 |
9811312001
|
|
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
|
Facility
|
IP
|
$672.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
9821312001
|
|
Hospital Revenue Code
|
982
|
| 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 |
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 2.6-7.5 CM
|
Facility
|
IP
|
$368.10
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
4501312101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$272.43 |
| Max. Negotiated Rate |
$349.69 |
| Rate for Payer: Aetna of VT Commercial |
$349.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$272.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$272.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$312.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$309.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$294.48
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna Commercial |
$294.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$294.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$294.48
|
| Rate for Payer: Multiplan Commercial |
$342.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$312.88
|
| Rate for Payer: United Healthcare Commercial |
$349.69
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
OP
|
$368.10
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
4501312101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$163.03 |
| Max. Negotiated Rate |
$349.69 |
| Rate for Payer: Aetna of VT Commercial |
$349.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$329.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$163.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$329.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$221.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$312.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$298.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$292.64
|
| Rate for Payer: Cash Price |
$184.05
|
| Rate for Payer: Cigna Commercial |
$294.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$294.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$294.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$165.65
|
| Rate for Payer: Multiplan Commercial |
$342.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$312.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$165.65
|
| Rate for Payer: United Healthcare Commercial |
$349.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$165.65
|
| Rate for Payer: United Healthcare VA CCN |
$165.65
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9821312101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$242.31 |
| Max. Negotiated Rate |
$928.72 |
| Rate for Payer: Aetna of VT Commercial |
$928.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$249.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$339.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$278.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$587.96
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$442.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$651.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$651.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$400.02
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$344.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare Commercial |
$372.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare VA CCN |
$242.31
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$437.59 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$437.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$594.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$800.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$444.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$785.46
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$444.60
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare VA CCN |
$444.60
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$437.59 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$437.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$594.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$800.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$444.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$785.46
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$444.60
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare VA CCN |
$444.60
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9821312101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$437.59 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$437.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$594.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$800.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$444.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$785.46
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$444.60
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.60
|
| Rate for Payer: United Healthcare VA CCN |
$444.60
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
IP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9821312101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$731.22 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$829.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$790.40
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$242.31 |
| Max. Negotiated Rate |
$928.72 |
| Rate for Payer: Aetna of VT Commercial |
$928.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$249.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$339.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$278.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$587.96
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$442.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$651.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$651.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$400.02
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$344.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare Commercial |
$372.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare VA CCN |
$242.31
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
IP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$731.22 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$829.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$790.40
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$242.31 |
| Max. Negotiated Rate |
$928.72 |
| Rate for Payer: Aetna of VT Commercial |
$928.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$249.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$885.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$339.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$587.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$278.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$587.96
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$442.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$651.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$651.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$400.02
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$344.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare Commercial |
$372.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.31
|
| Rate for Payer: United Healthcare VA CCN |
$242.31
|
|
|
CMPLX RPR S/A/L 2.6-7.5 CM
|
Facility
|
IP
|
$988.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
9811312101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$731.22 |
| Max. Negotiated Rate |
$938.60 |
| Rate for Payer: Aetna of VT Commercial |
$938.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$731.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$839.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$829.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$790.40
|
| Rate for Payer: Cash Price |
$494.00
|
| Rate for Payer: Cigna Commercial |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$790.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$790.40
|
| Rate for Payer: Multiplan Commercial |
$918.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$839.80
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9811312202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$374.12 |
| Rate for Payer: Aetna of VT Commercial |
$374.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$78.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$106.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$183.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$183.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.39
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$139.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$193.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$193.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.20
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$107.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$75.79
|
| Rate for Payer: United Healthcare Commercial |
$116.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.79
|
| Rate for Payer: United Healthcare VA CCN |
$75.79
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9811312201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$176.27 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna of VT Commercial |
$378.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$176.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$239.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$338.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$322.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$316.41
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$318.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$179.10
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare Commercial |
$378.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare VA CCN |
$179.10
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9811312202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$294.56 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna of VT Commercial |
$378.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$294.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$294.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$338.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$334.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$318.40
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$318.40
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.30
|
| Rate for Payer: United Healthcare Commercial |
$378.10
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9811312201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$374.12 |
| Rate for Payer: Aetna of VT Commercial |
$374.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$78.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$106.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$183.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$183.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.39
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$139.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$193.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$193.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$118.20
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$107.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$75.79
|
| Rate for Payer: United Healthcare Commercial |
$116.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.79
|
| Rate for Payer: United Healthcare VA CCN |
$75.79
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9821312201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$294.56 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna of VT Commercial |
$378.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$294.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$294.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$338.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$334.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$318.40
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$318.40
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.30
|
| Rate for Payer: United Healthcare Commercial |
$378.10
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
IP
|
$357.65
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
4501312201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$264.70 |
| Max. Negotiated Rate |
$339.77 |
| Rate for Payer: Aetna of VT Commercial |
$339.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$264.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$264.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$304.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$300.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$286.12
|
| Rate for Payer: Cash Price |
$178.82
|
| Rate for Payer: Cigna Commercial |
$286.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$286.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$286.12
|
| Rate for Payer: Multiplan Commercial |
$332.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$304.00
|
| Rate for Payer: United Healthcare Commercial |
$339.77
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9821312201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$176.27 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna of VT Commercial |
$378.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$176.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$239.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$338.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$322.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$316.41
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$318.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$179.10
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare Commercial |
$378.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare VA CCN |
$179.10
|
|
|
CMPLX RPR S/A/L ADDL 5 CM/>
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
9811312202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$176.27 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna of VT Commercial |
$378.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$176.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$356.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$239.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$338.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$322.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$179.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$316.41
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$318.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$318.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$179.10
|
| Rate for Payer: Multiplan Commercial |
$370.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare Commercial |
$378.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.10
|
| Rate for Payer: United Healthcare VA CCN |
$179.10
|
|
