|
1,3-BETA-D-GLUCAN (FUNGITELL)
|
Facility
|
IP
|
$118.91
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
3008744901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.01 |
| Max. Negotiated Rate |
$112.96 |
| Rate for Payer: Aetna of VT Commercial |
$112.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.13
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.13
|
| Rate for Payer: Multiplan Commercial |
$110.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.07
|
| Rate for Payer: United Healthcare Commercial |
$112.96
|
|
|
1,3-BETA-D-GLUCAN (FUNGITELL)
|
Facility
|
OP
|
$118.91
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
3008744902
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$112.96 |
| Rate for Payer: Aetna of VT Commercial |
$112.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$71.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.53
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.51
|
| Rate for Payer: Multiplan Commercial |
$110.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.51
|
| Rate for Payer: United Healthcare Commercial |
$112.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare VA CCN |
$53.51
|
|
|
1,3-BETA-D-GLUCAN (FUNGITELL)
|
Facility
|
IP
|
$118.91
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
3008744902
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.01 |
| Max. Negotiated Rate |
$112.96 |
| Rate for Payer: Aetna of VT Commercial |
$112.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.13
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.13
|
| Rate for Payer: Multiplan Commercial |
$110.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.07
|
| Rate for Payer: United Healthcare Commercial |
$112.96
|
|
|
1,3-BETA-D-GLUCAN (FUNGITELL)
|
Facility
|
OP
|
$118.91
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
3008744901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$112.96 |
| Rate for Payer: Aetna of VT Commercial |
$112.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$71.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.53
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cash Price |
$59.45
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.51
|
| Rate for Payer: Multiplan Commercial |
$110.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.51
|
| Rate for Payer: United Healthcare Commercial |
$112.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare VA CCN |
$53.51
|
|
|
36X35, FEM COMPONENT, 10.0 X 4
|
Facility
|
IP
|
$4,493.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,325.27 |
| Max. Negotiated Rate |
$4,268.35 |
| Rate for Payer: Aetna of VT Commercial |
$4,268.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,325.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,325.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,819.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,774.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,594.40
|
| Rate for Payer: Cash Price |
$2,246.50
|
| Rate for Payer: Cigna Commercial |
$3,594.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,594.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,594.40
|
| Rate for Payer: Multiplan Commercial |
$4,178.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,819.05
|
| Rate for Payer: United Healthcare Commercial |
$4,268.35
|
|
|
36X35, FEM COMPONENT, 10.0 X 4
|
Facility
|
OP
|
$4,493.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,989.95 |
| Max. Negotiated Rate |
$4,268.35 |
| Rate for Payer: Aetna of VT Commercial |
$4,268.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,025.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,989.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,025.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,704.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,819.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,639.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,021.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,571.93
|
| Rate for Payer: Cash Price |
$2,246.50
|
| Rate for Payer: Cigna Commercial |
$3,594.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,594.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,594.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,021.85
|
| Rate for Payer: Multiplan Commercial |
$4,178.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,819.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,021.85
|
| Rate for Payer: United Healthcare Commercial |
$4,268.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,021.85
|
| Rate for Payer: United Healthcare VA CCN |
$2,021.85
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
IP
|
$579.04
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
3507637601
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$428.55 |
| Max. Negotiated Rate |
$550.09 |
| Rate for Payer: Aetna of VT Commercial |
$550.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$428.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$428.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$492.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$486.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$463.23
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cigna Commercial |
$463.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$463.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$463.23
|
| Rate for Payer: Multiplan Commercial |
$538.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$492.18
|
| Rate for Payer: United Healthcare Commercial |
$550.09
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
IP
|
$341.00
|
|
|
Service Code
|
CPT 76377 26
|
| Hospital Charge Code |
9727637701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$252.37 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna of VT Commercial |
$323.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$252.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$252.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$289.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$286.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$272.80
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cigna Commercial |
$272.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$272.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$272.80
|
| Rate for Payer: Multiplan Commercial |
$317.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$289.85
|
| Rate for Payer: United Healthcare Commercial |
$323.95
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
9727637601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$24.47 |
| Max. Negotiated Rate |
$157.92 |
| Rate for Payer: Aetna of VT Commercial |
$157.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$36.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$28.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.96
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$36.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$24.47
|
| Rate for Payer: Multiplan Commercial |
$156.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$24.47
|
| Rate for Payer: United Healthcare Commercial |
$37.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.47
|
| Rate for Payer: United Healthcare VA CCN |
$24.47
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
9727637601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$74.41 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Aetna of VT Commercial |
$159.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$150.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$74.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$150.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$101.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$142.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$136.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$75.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$133.56
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$134.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$134.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$134.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$75.60
|
| Rate for Payer: Multiplan Commercial |
$156.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$142.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$159.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.60
|
| Rate for Payer: United Healthcare VA CCN |
$75.60
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
OP
|
$579.04
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
3507637601
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$67.73 |
| Max. Negotiated Rate |
$550.09 |
| Rate for Payer: Aetna of VT Commercial |
$550.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$492.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$469.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$260.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$460.34
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cigna Commercial |
$463.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$463.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$463.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$260.57
|
| Rate for Payer: Multiplan Commercial |
$538.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$492.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$260.57
|
| Rate for Payer: United Healthcare Commercial |
$550.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$260.57
|
| Rate for Payer: United Healthcare VA CCN |
$260.57
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
9727637601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Aetna of VT Commercial |
$159.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$142.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$141.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$134.40
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$134.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$134.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$134.40
|
| Rate for Payer: Multiplan Commercial |
$156.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$142.80
|
| Rate for Payer: United Healthcare Commercial |
$159.60
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
OP
|
$409.46
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3507637701
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$175.91 |
| Max. Negotiated Rate |
$388.99 |
| Rate for Payer: Aetna of VT Commercial |
$388.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$175.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$181.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$175.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$246.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$348.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$331.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$184.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$325.52
|
| Rate for Payer: Cash Price |
$204.73
|
| Rate for Payer: Cash Price |
$204.73
|
| Rate for Payer: Cigna Commercial |
$327.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$327.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$327.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$184.26
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$348.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$184.26
|
| Rate for Payer: United Healthcare Commercial |
$388.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.26
|
| Rate for Payer: United Healthcare VA CCN |
$184.26
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
OP
|
$341.00
|
|
|
Service Code
|
CPT 76377 26
|
| Hospital Charge Code |
9727637701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$151.03 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna of VT Commercial |
$323.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$305.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$151.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$305.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$205.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$289.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$276.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$153.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$271.10
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cigna Commercial |
$272.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$272.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$272.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$153.45
|
| Rate for Payer: Multiplan Commercial |
$317.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$289.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$153.45
|
| Rate for Payer: United Healthcare Commercial |
$323.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$153.45
|
| Rate for Payer: United Healthcare VA CCN |
$153.45
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
IP
|
$409.46
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3507637701
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$303.04 |
| Max. Negotiated Rate |
$388.99 |
| Rate for Payer: Aetna of VT Commercial |
$388.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$303.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$303.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$348.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$343.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$327.57
|
| Rate for Payer: Cash Price |
$204.73
|
| Rate for Payer: Cigna Commercial |
$327.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$327.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$327.57
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$348.04
|
| Rate for Payer: United Healthcare Commercial |
$388.99
|
|
|
3 MIN WALK TEST
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
9609461801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$144.76 |
| Rate for Payer: Aetna of VT Commercial |
$144.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$33.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$45.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$48.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$37.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.61
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna Commercial |
$48.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$52.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$52.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$32.73
|
| Rate for Payer: Multiplan Commercial |
$143.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$46.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$32.73
|
| Rate for Payer: United Healthcare Commercial |
$50.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.73
|
| Rate for Payer: United Healthcare VA CCN |
$32.73
|
|
|
3 MIN WALK TEST
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
9609461801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$113.98 |
| Max. Negotiated Rate |
$146.30 |
| Rate for Payer: Aetna of VT Commercial |
$146.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$123.20
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna Commercial |
$123.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$123.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$123.20
|
| Rate for Payer: Multiplan Commercial |
$143.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.90
|
| Rate for Payer: United Healthcare Commercial |
$146.30
|
|
|
3 MIN WALK TEST
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
9609461801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$68.21 |
| Max. Negotiated Rate |
$146.30 |
| Rate for Payer: Aetna of VT Commercial |
$146.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$68.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$92.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$124.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$122.43
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna Commercial |
$123.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$123.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$123.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$69.30
|
| Rate for Payer: Multiplan Commercial |
$143.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$69.30
|
| Rate for Payer: United Healthcare Commercial |
$146.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.30
|
| Rate for Payer: United Healthcare VA CCN |
$69.30
|
|
|
40MM BIOLOX DELTA HEAD M
|
Facility
|
OP
|
$1,144.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$506.68 |
| Max. Negotiated Rate |
$1,086.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,086.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$506.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,024.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$688.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$972.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$926.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$514.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$909.48
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cigna Commercial |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$915.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$514.80
|
| Rate for Payer: Multiplan Commercial |
$1,063.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$972.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$514.80
|
| Rate for Payer: United Healthcare Commercial |
$1,086.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$514.80
|
| Rate for Payer: United Healthcare VA CCN |
$514.80
|
|
|
40MM BIOLOX DELTA HEAD M
|
Facility
|
OP
|
$1,100.00
|
|
| Hospital Charge Code |
2720074581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$487.19 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,045.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$985.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$487.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$985.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$662.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$935.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$891.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$495.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$874.50
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$880.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$880.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$880.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$495.00
|
| Rate for Payer: Multiplan Commercial |
$1,023.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$935.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$495.00
|
| Rate for Payer: United Healthcare Commercial |
$1,045.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$495.00
|
| Rate for Payer: United Healthcare VA CCN |
$495.00
|
|
|
40MM BIOLOX DELTA HEAD M
|
Facility
|
IP
|
$1,144.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$846.67 |
| Max. Negotiated Rate |
$1,086.80 |
| Rate for Payer: Aetna of VT Commercial |
$1,086.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$846.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$846.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$972.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$960.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$915.20
|
| Rate for Payer: Cash Price |
$572.00
|
| Rate for Payer: Cigna Commercial |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$915.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$915.20
|
| Rate for Payer: Multiplan Commercial |
$1,063.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$972.40
|
| Rate for Payer: United Healthcare Commercial |
$1,086.80
|
|
|
40MM BIOLOX DELTA HEAD M
|
Facility
|
IP
|
$1,100.00
|
|
| Hospital Charge Code |
2720074581
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$814.11 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,045.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$814.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$814.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$935.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$924.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$880.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$880.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$880.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$880.00
|
| Rate for Payer: Multiplan Commercial |
$1,023.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$935.00
|
| Rate for Payer: United Healthcare Commercial |
$1,045.00
|
|
|
4V HPV VAC 3 DOSE IM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
6369064901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
4V HPV VAC 3 DOSE IM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
6369064901
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
4V HPV VAC 3 DOSE IM
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
6369064901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$226.72 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$174.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$174.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$174.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$226.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$226.72
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$196.00
|
|
