|
ALPHA-FETOPROTEIN SERUM
|
Professional
|
Both
|
$230.72
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
3008210501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.54 |
| Max. Negotiated Rate |
$216.88 |
| Rate for Payer: Aetna of VT Commercial |
$216.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$82.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$82.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$28.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$28.66
|
| Rate for Payer: Cash Price |
$115.36
|
| Rate for Payer: Cash Price |
$115.36
|
| Rate for Payer: Cigna Commercial |
$20.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.77
|
| Rate for Payer: Martins Point Health Care Commercial |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$214.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$16.77
|
| Rate for Payer: United Healthcare Commercial |
$25.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.77
|
| Rate for Payer: United Healthcare VA CCN |
$16.77
|
|
|
ALPHA-FETOPROTEIN SERUM
|
Facility
|
OP
|
$230.72
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
3008210501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$219.18 |
| Rate for Payer: Aetna of VT Commercial |
$219.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$82.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$82.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$196.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$186.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.42
|
| Rate for Payer: Cash Price |
$115.36
|
| Rate for Payer: Cash Price |
$115.36
|
| Rate for Payer: Cigna Commercial |
$184.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.82
|
| Rate for Payer: Multiplan Commercial |
$214.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$196.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.82
|
| Rate for Payer: United Healthcare Commercial |
$219.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.77
|
| Rate for Payer: United Healthcare VA CCN |
$103.82
|
|
|
AMINOCAPROIC ACID 5G/20ML VIAL
|
Facility
|
IP
|
$49.95
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
636J028101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.97 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna of VT Commercial |
$47.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$36.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$36.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$42.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.96
|
| Rate for Payer: Cash Price |
$24.98
|
| Rate for Payer: Cigna Commercial |
$39.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.96
|
| Rate for Payer: Multiplan Commercial |
$46.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.46
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
|
|
AMINOCAPROIC ACID 5G/20ML VIAL
|
Facility
|
OP
|
$49.95
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
636J028101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna of VT Commercial |
$47.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$22.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$30.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$42.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.71
|
| Rate for Payer: Cash Price |
$24.98
|
| Rate for Payer: Cash Price |
$24.98
|
| Rate for Payer: Cigna Commercial |
$39.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.48
|
| Rate for Payer: Multiplan Commercial |
$46.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.48
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.48
|
| Rate for Payer: United Healthcare VA CCN |
$22.48
|
|
|
AMINOPHYLLINE 250MG/10ML
|
Facility
|
IP
|
$73.64
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
636J028002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.50 |
| Max. Negotiated Rate |
$69.96 |
| Rate for Payer: Aetna of VT Commercial |
$69.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$61.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.91
|
| Rate for Payer: Cash Price |
$36.82
|
| Rate for Payer: Cigna Commercial |
$58.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.91
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.59
|
| Rate for Payer: United Healthcare Commercial |
$69.96
|
|
|
AMINOPHYLLINE 250MG/10ML
|
Facility
|
OP
|
$73.64
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
636J028002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.39 |
| Max. Negotiated Rate |
$69.96 |
| Rate for Payer: Aetna of VT Commercial |
$69.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$30.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$32.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$30.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$44.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.54
|
| Rate for Payer: Cash Price |
$36.82
|
| Rate for Payer: Cash Price |
$36.82
|
| Rate for Payer: Cigna Commercial |
$58.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.14
|
| Rate for Payer: Multiplan Commercial |
$68.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.14
|
| Rate for Payer: United Healthcare Commercial |
$69.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.14
|
| Rate for Payer: United Healthcare VA CCN |
$33.14
|
|
|
AMINOPHYLLINE 500 MG/20 ML VIA
|
Facility
|
IP
|
$49.21
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
636J028001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.42 |
| Max. Negotiated Rate |
$46.75 |
| Rate for Payer: Aetna of VT Commercial |
$46.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$36.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$36.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$41.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.37
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$39.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.37
|
| Rate for Payer: Multiplan Commercial |
$45.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$41.83
|
| Rate for Payer: United Healthcare Commercial |
$46.75
|
|
|
AMINOPHYLLINE 500 MG/20 ML VIA
|
Facility
|
OP
|
$49.21
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
636J028001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.80 |
| Max. Negotiated Rate |
$46.75 |
| Rate for Payer: Aetna of VT Commercial |
$46.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$30.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$21.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$30.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$29.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$41.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$39.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.12
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$39.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.37
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.37
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.14
|
| Rate for Payer: Multiplan Commercial |
$45.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$41.83
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.14
|
| Rate for Payer: United Healthcare Commercial |
$46.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.14
|
| Rate for Payer: United Healthcare VA CCN |
$22.14
|
|
|
AMIODARONE 900 MG/18 ML VIAL
|
Facility
|
IP
|
$83.56
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
636J028202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna of VT Commercial |
$79.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$61.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$61.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$70.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$66.85
|
| Rate for Payer: Cash Price |
$41.78
|
| Rate for Payer: Cigna Commercial |
$66.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$66.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$66.85
|
| Rate for Payer: Multiplan Commercial |
$77.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.03
|
| Rate for Payer: United Healthcare Commercial |
$79.38
|
|
|
AMIODARONE 900 MG/18 ML VIAL
|
Facility
|
OP
|
$83.56
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
636J028202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna of VT Commercial |
$79.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$37.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$67.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$37.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$66.43
|
| Rate for Payer: Cash Price |
$41.78
|
| Rate for Payer: Cash Price |
$41.78
|
| Rate for Payer: Cigna Commercial |
$66.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$66.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$66.85
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.60
|
| Rate for Payer: Multiplan Commercial |
$77.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.60
|
| Rate for Payer: United Healthcare Commercial |
$79.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.60
|
| Rate for Payer: United Healthcare VA CCN |
$37.60
|
|
|
AMISTEM-P COLLARED LAT #5
|
Facility
|
OP
|
$3,304.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073821
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,463.34 |
| Max. Negotiated Rate |
$3,138.80 |
| Rate for Payer: Aetna of VT Commercial |
$3,138.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,960.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,463.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,960.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,989.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,808.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,676.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,486.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,626.68
|
| Rate for Payer: Cash Price |
$1,652.00
|
| Rate for Payer: Cigna Commercial |
$2,643.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,643.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,643.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,486.80
|
| Rate for Payer: Multiplan Commercial |
$3,072.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,808.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,486.80
|
| Rate for Payer: United Healthcare Commercial |
$3,138.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,486.80
|
| Rate for Payer: United Healthcare VA CCN |
$1,486.80
|
|
|
AMISTEM-P COLLARED LAT #5
|
Facility
|
IP
|
$3,304.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073821
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,445.29 |
| Max. Negotiated Rate |
$3,138.80 |
| Rate for Payer: Aetna of VT Commercial |
$3,138.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,445.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,445.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,808.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,775.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,643.20
|
| Rate for Payer: Cash Price |
$1,652.00
|
| Rate for Payer: Cigna Commercial |
$2,643.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,643.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,643.20
|
| Rate for Payer: Multiplan Commercial |
$3,072.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,808.40
|
| Rate for Payer: United Healthcare Commercial |
$3,138.80
|
|
|
AMISTEM-P COLLARED STD #6
|
Facility
|
IP
|
$3,308.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,448.84 |
| Max. Negotiated Rate |
$3,143.36 |
| Rate for Payer: Aetna of VT Commercial |
$3,143.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,448.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,448.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,812.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,779.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,647.04
|
| Rate for Payer: Cash Price |
$1,654.40
|
| Rate for Payer: Cigna Commercial |
$2,647.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,647.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,647.04
|
| Rate for Payer: Multiplan Commercial |
$3,077.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,812.48
|
| Rate for Payer: United Healthcare Commercial |
$3,143.36
|
|
|
AMISTEM-P COLLARED STD #6
|
Facility
|
OP
|
$3,308.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,465.47 |
| Max. Negotiated Rate |
$3,143.36 |
| Rate for Payer: Aetna of VT Commercial |
$3,143.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,964.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,465.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,964.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,991.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,812.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,680.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,488.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,630.50
|
| Rate for Payer: Cash Price |
$1,654.40
|
| Rate for Payer: Cigna Commercial |
$2,647.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,647.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,647.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,488.96
|
| Rate for Payer: Multiplan Commercial |
$3,077.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,812.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,488.96
|
| Rate for Payer: United Healthcare Commercial |
$3,143.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,488.96
|
| Rate for Payer: United Healthcare VA CCN |
$1,488.96
|
|
|
AMISTEM-P COLLARED STD #7
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,550.15 |
| Max. Negotiated Rate |
$3,325.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,325.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,135.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,550.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,135.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,107.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,975.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,835.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,575.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,782.50
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,800.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,575.00
|
| Rate for Payer: Multiplan Commercial |
$3,255.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,975.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,575.00
|
| Rate for Payer: United Healthcare Commercial |
$3,325.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,575.00
|
| Rate for Payer: United Healthcare VA CCN |
$1,575.00
|
|
|
AMISTEM-P COLLARED STD #7
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,590.35 |
| Max. Negotiated Rate |
$3,325.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,325.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,590.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,590.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,975.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,940.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,800.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,800.00
|
| Rate for Payer: Multiplan Commercial |
$3,255.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,975.00
|
| Rate for Payer: United Healthcare Commercial |
$3,325.00
|
|
|
AMISTEM-P COLLARED STD #8
|
Facility
|
IP
|
$3,296.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073711
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.37 |
| Max. Negotiated Rate |
$3,131.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,131.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,439.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,439.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,801.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,768.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,636.80
|
| Rate for Payer: Cash Price |
$1,648.00
|
| Rate for Payer: Cigna Commercial |
$2,636.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,636.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,636.80
|
| Rate for Payer: Multiplan Commercial |
$3,065.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,801.60
|
| Rate for Payer: United Healthcare Commercial |
$3,131.20
|
|
|
AMISTEM-P COLLARED STD #8
|
Facility
|
OP
|
$3,296.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073711
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.80 |
| Max. Negotiated Rate |
$3,131.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,131.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,952.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,459.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,952.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,984.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,801.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,669.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,483.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,620.32
|
| Rate for Payer: Cash Price |
$1,648.00
|
| Rate for Payer: Cigna Commercial |
$2,636.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,636.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,636.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,483.20
|
| Rate for Payer: Multiplan Commercial |
$3,065.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,801.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,483.20
|
| Rate for Payer: United Healthcare Commercial |
$3,131.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,483.20
|
| Rate for Payer: United Healthcare VA CCN |
$1,483.20
|
|
|
AMPHETAMINES 3OR 4
|
Professional
|
Both
|
$61.26
|
|
|
Service Code
|
CPT 80325
|
| Hospital Charge Code |
3008032501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$223.41 |
| Rate for Payer: Aetna of VT Commercial |
$57.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.88
|
| Rate for Payer: Cash Price |
$30.63
|
| Rate for Payer: Cash Price |
$30.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$223.41
|
| Rate for Payer: Multiplan Commercial |
$56.97
|
| Rate for Payer: United Healthcare Commercial |
$52.07
|
| Rate for Payer: United Healthcare VA CCN |
$24.50
|
|
|
AMPHETAMINES 3OR 4
|
Facility
|
IP
|
$61.26
|
|
|
Service Code
|
CPT 80325
|
| Hospital Charge Code |
3008032501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.34 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Aetna of VT Commercial |
$58.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$45.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$45.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.01
|
| Rate for Payer: Cash Price |
$30.63
|
| Rate for Payer: Cigna Commercial |
$49.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.01
|
| Rate for Payer: Multiplan Commercial |
$56.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.07
|
| Rate for Payer: United Healthcare Commercial |
$58.20
|
|
|
AMPHETAMINES 3OR 4
|
Facility
|
OP
|
$61.26
|
|
|
Service Code
|
CPT 80325
|
| Hospital Charge Code |
3008032501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.13 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Aetna of VT Commercial |
$58.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$36.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.70
|
| Rate for Payer: Cash Price |
$30.63
|
| Rate for Payer: Cigna Commercial |
$49.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.57
|
| Rate for Payer: Multiplan Commercial |
$56.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.57
|
| Rate for Payer: United Healthcare Commercial |
$58.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.57
|
| Rate for Payer: United Healthcare VA CCN |
$27.57
|
|
|
AMPHOTERICIN B LIPOSOME 50MG
|
Facility
|
OP
|
$840.06
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
636J028901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.10 |
| Max. Negotiated Rate |
$798.06 |
| Rate for Payer: Aetna of VT Commercial |
$798.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$372.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$505.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$714.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$680.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$378.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$667.85
|
| Rate for Payer: Cash Price |
$420.03
|
| Rate for Payer: Cash Price |
$420.03
|
| Rate for Payer: Cigna Commercial |
$672.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$378.03
|
| Rate for Payer: Multiplan Commercial |
$781.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$714.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$378.03
|
| Rate for Payer: United Healthcare Commercial |
$798.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$378.03
|
| Rate for Payer: United Healthcare VA CCN |
$378.03
|
|
|
AMPHOTERICIN B LIPOSOME 50MG
|
Facility
|
IP
|
$840.06
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
636J028901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$621.73 |
| Max. Negotiated Rate |
$798.06 |
| Rate for Payer: Aetna of VT Commercial |
$798.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$621.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$621.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$714.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$705.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$672.05
|
| Rate for Payer: Cash Price |
$420.03
|
| Rate for Payer: Cigna Commercial |
$672.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$672.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$672.05
|
| Rate for Payer: Multiplan Commercial |
$781.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$714.05
|
| Rate for Payer: United Healthcare Commercial |
$798.06
|
|
|
AMPUTATION OF FINGER/THUMB
|
Facility
|
IP
|
$1,968.00
|
|
|
Service Code
|
CPT 26952
|
| Hospital Charge Code |
9812695202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,456.52 |
| Max. Negotiated Rate |
$1,869.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,869.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,456.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,456.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,672.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,653.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,574.40
|
| Rate for Payer: Cash Price |
$984.00
|
| Rate for Payer: Cigna Commercial |
$1,574.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,574.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,574.40
|
| Rate for Payer: Multiplan Commercial |
$1,830.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,672.80
|
| Rate for Payer: United Healthcare Commercial |
$1,869.60
|
|
|
AMPUTATION OF FINGER/THUMB
|
Facility
|
OP
|
$1,968.00
|
|
|
Service Code
|
CPT 26952
|
| Hospital Charge Code |
9812695202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$871.63 |
| Max. Negotiated Rate |
$1,869.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,869.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,763.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$871.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,763.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,184.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,672.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,594.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$885.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,564.56
|
| Rate for Payer: Cash Price |
$984.00
|
| Rate for Payer: Cigna Commercial |
$1,574.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,574.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,574.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$885.60
|
| Rate for Payer: Multiplan Commercial |
$1,830.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,672.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$885.60
|
| Rate for Payer: United Healthcare Commercial |
$1,869.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$885.60
|
| Rate for Payer: United Healthcare VA CCN |
$885.60
|
|
