|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$429.38
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
4503659301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$190.17 |
| Max. Negotiated Rate |
$407.91 |
| Rate for Payer: Aetna of VT Commercial |
$407.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$384.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$190.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$384.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$258.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$364.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$193.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$341.36
|
| Rate for Payer: Cash Price |
$214.69
|
| Rate for Payer: Cigna Commercial |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$343.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$343.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$193.22
|
| Rate for Payer: Multiplan Commercial |
$399.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$364.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$193.22
|
| Rate for Payer: United Healthcare Commercial |
$407.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$193.22
|
| Rate for Payer: United Healthcare VA CCN |
$193.22
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9813659301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$192.66 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$192.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$389.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$261.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$352.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$195.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$345.82
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$195.75
|
| Rate for Payer: United Healthcare VA CCN |
$195.75
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
9813659301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$321.94 |
| Max. Negotiated Rate |
$413.25 |
| Rate for Payer: Aetna of VT Commercial |
$413.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$321.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$369.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$365.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$348.00
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.00
|
| Rate for Payer: Multiplan Commercial |
$404.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$369.75
|
| Rate for Payer: United Healthcare Commercial |
$413.25
|
|
|
DECOMPRESSION OF LOWER LEG
|
Facility
|
OP
|
$1,701.00
|
|
|
Service Code
|
CPT 27602
|
| Hospital Charge Code |
9822760201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$753.37 |
| Max. Negotiated Rate |
$1,615.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,615.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,523.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$753.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,523.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,024.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,445.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,377.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$765.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,352.30
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: Cigna Commercial |
$1,360.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,360.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,360.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$765.45
|
| Rate for Payer: Multiplan Commercial |
$1,581.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,445.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$765.45
|
| Rate for Payer: United Healthcare Commercial |
$1,615.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$765.45
|
| Rate for Payer: United Healthcare VA CCN |
$765.45
|
|
|
DECOMPRESSION OF LOWER LEG
|
Facility
|
IP
|
$1,701.00
|
|
|
Service Code
|
CPT 27602
|
| Hospital Charge Code |
9822760201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,258.91 |
| Max. Negotiated Rate |
$1,615.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,615.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,258.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,258.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,445.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,428.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,360.80
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: Cigna Commercial |
$1,360.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,360.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,360.80
|
| Rate for Payer: Multiplan Commercial |
$1,581.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,445.85
|
| Rate for Payer: United Healthcare Commercial |
$1,615.95
|
|
|
DECOMPRESSION OF LOWER LEG
|
Professional
|
Both
|
$1,701.00
|
|
|
Service Code
|
CPT 27602
|
| Hospital Charge Code |
9822760201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$433.17 |
| Max. Negotiated Rate |
$1,598.94 |
| Rate for Payer: Aetna of VT Commercial |
$1,598.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,523.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$446.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,523.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$606.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$927.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$927.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$498.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$927.48
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: Cigna Commercial |
$825.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$737.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$737.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$433.17
|
| Rate for Payer: Multiplan Commercial |
$1,581.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$615.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$433.17
|
| Rate for Payer: United Healthcare Commercial |
$666.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$433.17
|
| Rate for Payer: United Healthcare VA CCN |
$433.17
|
|
|
DEGARELIX (FIRMAGON) 120 MG VL
|
Facility
|
OP
|
$2,978.49
|
|
|
Service Code
|
NDC 5556684031
|
| Hospital Charge Code |
636J915501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,319.17 |
| Max. Negotiated Rate |
$2,829.57 |
| Rate for Payer: Aetna of VT Commercial |
$2,829.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,668.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,319.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,668.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,793.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,531.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,412.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,340.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,367.90
|
| Rate for Payer: Cash Price |
$1,489.24
|
| Rate for Payer: Cigna Commercial |
$2,382.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,382.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,382.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,340.32
|
| Rate for Payer: Multiplan Commercial |
$2,770.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,531.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,340.32
|
| Rate for Payer: United Healthcare Commercial |
$2,829.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,340.32
|
| Rate for Payer: United Healthcare VA CCN |
$1,340.32
|
|
|
DEGARELIX (FIRMAGON) 120 MG VL
|
Facility
|
IP
|
$2,978.49
|
|
|
Service Code
|
NDC 5556684031
|
| Hospital Charge Code |
636J915501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,204.38 |
| Max. Negotiated Rate |
$2,829.57 |
| Rate for Payer: Aetna of VT Commercial |
$2,829.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,204.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,204.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,531.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,501.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,382.79
|
| Rate for Payer: Cash Price |
$1,489.24
|
| Rate for Payer: Cigna Commercial |
$2,382.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,382.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,382.79
|
| Rate for Payer: Multiplan Commercial |
$2,770.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,531.72
|
| Rate for Payer: United Healthcare Commercial |
$2,829.57
|
|
|
DEHYDROEPIANDROSTERONE
|
Facility
|
OP
|
$444.84
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
3008262601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.27 |
| Max. Negotiated Rate |
$422.60 |
| Rate for Payer: Aetna of VT Commercial |
$422.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$197.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$267.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$378.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$360.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$353.65
|
| Rate for Payer: Cash Price |
$222.42
|
| Rate for Payer: Cash Price |
$222.42
|
| Rate for Payer: Cigna Commercial |
$355.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$200.18
|
| Rate for Payer: Multiplan Commercial |
$413.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$378.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$200.18
|
| Rate for Payer: United Healthcare Commercial |
$422.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.27
|
| Rate for Payer: United Healthcare VA CCN |
$200.18
|
|
|
DEHYDROEPIANDROSTERONE
|
Facility
|
IP
|
$444.84
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
3008262601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$329.23 |
| Max. Negotiated Rate |
$422.60 |
| Rate for Payer: Aetna of VT Commercial |
$422.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$329.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$329.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$378.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$373.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$355.87
|
| Rate for Payer: Cash Price |
$222.42
|
| Rate for Payer: Cigna Commercial |
$355.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$355.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$355.87
|
| Rate for Payer: Multiplan Commercial |
$413.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$378.11
|
| Rate for Payer: United Healthcare Commercial |
$422.60
|
|
|
DEHYDROEPIANDROSTERONE
|
Professional
|
Both
|
$444.84
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
3008262601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$418.15 |
| Rate for Payer: Aetna of VT Commercial |
$418.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$26.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$35.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$29.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$43.20
|
| Rate for Payer: Cash Price |
$222.42
|
| Rate for Payer: Cash Price |
$222.42
|
| Rate for Payer: Cigna Commercial |
$30.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$25.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$25.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$24.92
|
| Rate for Payer: Multiplan Commercial |
$413.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$25.27
|
| Rate for Payer: United Healthcare Commercial |
$38.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.27
|
| Rate for Payer: United Healthcare VA CCN |
$25.27
|
|
|
DEHYDROEPIANDROSTERONE-SULFATE
|
Professional
|
Both
|
$283.37
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
3008262701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.92 |
| Max. Negotiated Rate |
$266.37 |
| Rate for Payer: Aetna of VT Commercial |
$266.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$109.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$22.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$109.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$38.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$25.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$38.00
|
| Rate for Payer: Cash Price |
$141.68
|
| Rate for Payer: Cash Price |
$141.68
|
| Rate for Payer: Cigna Commercial |
$26.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$21.92
|
| Rate for Payer: Multiplan Commercial |
$263.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.23
|
| Rate for Payer: United Healthcare Commercial |
$34.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.23
|
| Rate for Payer: United Healthcare VA CCN |
$22.23
|
|
|
DEHYDROEPIANDROSTERONE-SULFATE
|
Facility
|
OP
|
$283.37
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
3008262701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$269.20 |
| Rate for Payer: Aetna of VT Commercial |
$269.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$109.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$125.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$109.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$170.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$240.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$229.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$127.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$225.28
|
| Rate for Payer: Cash Price |
$141.68
|
| Rate for Payer: Cash Price |
$141.68
|
| Rate for Payer: Cigna Commercial |
$226.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$226.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$226.70
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.52
|
| Rate for Payer: Multiplan Commercial |
$263.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$127.52
|
| Rate for Payer: United Healthcare Commercial |
$269.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.23
|
| Rate for Payer: United Healthcare VA CCN |
$127.52
|
|
|
DEHYDROEPIANDROSTERONE-SULFATE
|
Facility
|
IP
|
$283.37
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
3008262701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$209.72 |
| Max. Negotiated Rate |
$269.20 |
| Rate for Payer: Aetna of VT Commercial |
$269.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$209.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$209.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$240.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$238.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$226.70
|
| Rate for Payer: Cash Price |
$141.68
|
| Rate for Payer: Cigna Commercial |
$226.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$226.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$226.70
|
| Rate for Payer: Multiplan Commercial |
$263.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.86
|
| Rate for Payer: United Healthcare Commercial |
$269.20
|
|
|
DELIVER PLACENTA SEP PROC
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9695941401
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$175.39 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna of VT Commercial |
$376.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$175.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$238.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$336.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$320.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$314.82
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$316.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$336.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$178.20
|
| Rate for Payer: United Healthcare Commercial |
$376.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$178.20
|
| Rate for Payer: United Healthcare VA CCN |
$178.20
|
|
|
DELIVER PLACENTA SEP PROC
|
Professional
|
Both
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9695941401
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$80.37 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna of VT Commercial |
$372.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$92.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.60
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$140.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$140.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.97
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.37
|
| Rate for Payer: United Healthcare Commercial |
$123.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.37
|
| Rate for Payer: United Healthcare VA CCN |
$80.37
|
|
|
DELIVER PLACENTA SEP PROC
|
Professional
|
Both
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9825941401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$80.37 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna of VT Commercial |
$372.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$92.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.60
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$140.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$140.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.97
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.37
|
| Rate for Payer: United Healthcare Commercial |
$123.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.37
|
| Rate for Payer: United Healthcare VA CCN |
$80.37
|
|
|
DELIVER PLACENTA SEP PROC
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9825941401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$175.39 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna of VT Commercial |
$376.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$175.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$354.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$238.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$336.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$320.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$314.82
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$316.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$336.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$178.20
|
| Rate for Payer: United Healthcare Commercial |
$376.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$178.20
|
| Rate for Payer: United Healthcare VA CCN |
$178.20
|
|
|
DELIVER PLACENTA SEP PROC
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9825941401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$293.08 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna of VT Commercial |
$376.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$293.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$293.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$336.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$332.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$316.80
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$316.80
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$336.60
|
| Rate for Payer: United Healthcare Commercial |
$376.20
|
|
|
DELIVER PLACENTA SEP PROC
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 59414
|
| Hospital Charge Code |
9695941401
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$293.08 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna of VT Commercial |
$376.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$293.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$293.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$336.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$332.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$316.80
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$316.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$316.80
|
| Rate for Payer: Multiplan Commercial |
$368.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$336.60
|
| Rate for Payer: United Healthcare Commercial |
$376.20
|
|
|
DELIVERY
|
Facility
|
IP
|
$3,872.33
|
|
| Hospital Charge Code |
7220000001
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$2,865.91 |
| Max. Negotiated Rate |
$3,678.71 |
| Rate for Payer: Aetna of VT Commercial |
$3,678.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,865.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,865.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,291.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,252.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,097.86
|
| Rate for Payer: Cash Price |
$1,936.16
|
| Rate for Payer: Cigna Commercial |
$3,097.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,097.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,097.86
|
| Rate for Payer: Multiplan Commercial |
$3,601.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,291.48
|
| Rate for Payer: United Healthcare Commercial |
$3,678.71
|
|
|
DELIVERY
|
Facility
|
OP
|
$3,872.33
|
|
| Hospital Charge Code |
7220000001
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$1,715.05 |
| Max. Negotiated Rate |
$3,678.71 |
| Rate for Payer: Aetna of VT Commercial |
$3,678.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,469.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,715.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,469.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,331.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,291.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,136.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,742.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,078.50
|
| Rate for Payer: Cash Price |
$1,936.16
|
| Rate for Payer: Cigna Commercial |
$3,097.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,097.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,097.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,742.55
|
| Rate for Payer: Multiplan Commercial |
$3,601.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,291.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,742.55
|
| Rate for Payer: United Healthcare Commercial |
$3,678.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,742.55
|
| Rate for Payer: United Healthcare VA CCN |
$1,742.55
|
|
|
DELIVERY LEVEL II
|
Facility
|
OP
|
$6,402.53
|
|
| Hospital Charge Code |
7220000002
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$2,835.68 |
| Max. Negotiated Rate |
$6,082.40 |
| Rate for Payer: Aetna of VT Commercial |
$6,082.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,736.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,835.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,736.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,854.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,442.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,186.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,881.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,090.01
|
| Rate for Payer: Cash Price |
$3,201.26
|
| Rate for Payer: Cigna Commercial |
$5,122.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,122.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,122.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,881.14
|
| Rate for Payer: Multiplan Commercial |
$5,954.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,442.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,881.14
|
| Rate for Payer: United Healthcare Commercial |
$6,082.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,881.14
|
| Rate for Payer: United Healthcare VA CCN |
$2,881.14
|
|
|
DELIVERY LEVEL II
|
Facility
|
IP
|
$6,402.53
|
|
| Hospital Charge Code |
7220000002
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$4,738.51 |
| Max. Negotiated Rate |
$6,082.40 |
| Rate for Payer: Aetna of VT Commercial |
$6,082.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,738.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,738.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,442.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,378.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,122.02
|
| Rate for Payer: Cash Price |
$3,201.26
|
| Rate for Payer: Cigna Commercial |
$5,122.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,122.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,122.02
|
| Rate for Payer: Multiplan Commercial |
$5,954.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,442.15
|
| Rate for Payer: United Healthcare Commercial |
$6,082.40
|
|
|
DELIVERY LEVEL III
|
Facility
|
OP
|
$8,932.73
|
|
| Hospital Charge Code |
7220000003
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$3,956.31 |
| Max. Negotiated Rate |
$8,486.09 |
| Rate for Payer: Aetna of VT Commercial |
$8,486.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8,002.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,956.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8,002.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5,377.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,592.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7,235.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4,019.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7,101.52
|
| Rate for Payer: Cash Price |
$4,466.36
|
| Rate for Payer: Cigna Commercial |
$7,146.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7,146.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7,146.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$4,019.73
|
| Rate for Payer: Multiplan Commercial |
$8,307.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,592.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4,019.73
|
| Rate for Payer: United Healthcare Commercial |
$8,486.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,019.73
|
| Rate for Payer: United Healthcare VA CCN |
$4,019.73
|
|
