|
DELIVERY LEVEL III
|
Facility
|
IP
|
$8,932.73
|
|
| Hospital Charge Code |
7220000003
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$6,611.11 |
| 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 |
$6,611.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,611.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,592.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7,503.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7,146.18
|
| 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: Multiplan Commercial |
$8,307.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,592.82
|
| Rate for Payer: United Healthcare Commercial |
$8,486.09
|
|
|
DELIVERY LEVEL IV
|
Facility
|
IP
|
$11,462.92
|
|
| Hospital Charge Code |
7220000004
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$8,483.71 |
| Max. Negotiated Rate |
$10,889.77 |
| Rate for Payer: Aetna of VT Commercial |
$10,889.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8,483.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8,483.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9,743.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9,628.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9,170.34
|
| Rate for Payer: Cash Price |
$5,731.46
|
| Rate for Payer: Cigna Commercial |
$9,170.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9,170.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9,170.34
|
| Rate for Payer: Multiplan Commercial |
$10,660.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,743.48
|
| Rate for Payer: United Healthcare Commercial |
$10,889.77
|
|
|
DELIVERY LEVEL IV
|
Facility
|
OP
|
$11,462.92
|
|
| Hospital Charge Code |
7220000004
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$5,076.93 |
| Max. Negotiated Rate |
$10,889.77 |
| Rate for Payer: Aetna of VT Commercial |
$10,889.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$10,269.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5,076.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$10,269.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$6,900.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9,743.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9,284.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$5,158.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9,113.02
|
| Rate for Payer: Cash Price |
$5,731.46
|
| Rate for Payer: Cigna Commercial |
$9,170.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9,170.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9,170.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$5,158.31
|
| Rate for Payer: Multiplan Commercial |
$10,660.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9,743.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5,158.31
|
| Rate for Payer: United Healthcare Commercial |
$10,889.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,158.31
|
| Rate for Payer: United Healthcare VA CCN |
$5,158.31
|
|
|
DENOSUMAB 120 MG/1.7 ML VIAL
|
Facility
|
OP
|
$76.48
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.48 |
| Max. Negotiated Rate |
$76.48 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
|
|
DENOSUMAB 120 MG/1.7 ML VIAL
|
Professional
|
Both
|
$8,618.05
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.66 |
| Max. Negotiated Rate |
$8,100.97 |
| Rate for Payer: Aetna of VT Commercial |
$8,100.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$41.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.79
|
| Rate for Payer: Cash Price |
$4,309.02
|
| Rate for Payer: Cash Price |
$4,309.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.81
|
| Rate for Payer: Multiplan Commercial |
$8,014.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare Commercial |
$45.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare VA CCN |
$29.38
|
|
|
DENOSUMAB 120 MG/1.7 ML VIAL *
|
Professional
|
Both
|
$5,225.13
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.66 |
| Max. Negotiated Rate |
$4,911.62 |
| Rate for Payer: Aetna of VT Commercial |
$4,911.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$41.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.79
|
| Rate for Payer: Cash Price |
$2,612.56
|
| Rate for Payer: Cash Price |
$2,612.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.81
|
| Rate for Payer: Multiplan Commercial |
$4,859.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare Commercial |
$45.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare VA CCN |
$29.38
|
|
|
DENOSUMAB 120MG/1.7MLVIAL 340B
|
Professional
|
Both
|
$5,225.13
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.66 |
| Max. Negotiated Rate |
$4,911.62 |
| Rate for Payer: Aetna of VT Commercial |
$4,911.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$41.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.79
|
| Rate for Payer: Cash Price |
$2,612.56
|
| Rate for Payer: Cash Price |
$2,612.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.81
|
| Rate for Payer: Multiplan Commercial |
$4,859.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare Commercial |
$45.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare VA CCN |
$29.38
|
|
|
DENOSUMAB 120MG/1.7MLVIAL 340B
|
Facility
|
OP
|
$76.48
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.48 |
| Max. Negotiated Rate |
$76.48 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
|
|
DENOSUMAB 60 MG/ML SYRINGE
|
Facility
|
OP
|
$76.48
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.48 |
| Max. Negotiated Rate |
$76.48 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
|
|
DENOSUMAB 60 MG/ML SYRINGE
|
Professional
|
Both
|
$7,239.16
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
636J089701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.66 |
| Max. Negotiated Rate |
$6,804.81 |
| Rate for Payer: Aetna of VT Commercial |
$6,804.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$41.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.79
|
| Rate for Payer: Cash Price |
$3,619.58
|
| Rate for Payer: Cash Price |
$3,619.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.81
|
| Rate for Payer: Multiplan Commercial |
$6,732.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$29.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare Commercial |
$45.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.38
|
| Rate for Payer: United Healthcare VA CCN |
$29.38
|
|
|
DEOXYRIBONUCLEASE ANTIBODY
|
Professional
|
Both
|
$198.53
|
|
|
Service Code
|
CPT 86215
|
| Hospital Charge Code |
3008621501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$186.62 |
| Rate for Payer: Aetna of VT Commercial |
$186.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.65
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.06
|
| Rate for Payer: Multiplan Commercial |
$184.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare Commercial |
$20.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare VA CCN |
$13.25
|
|
|
DEOXYRIBONUCLEASE ANTIBODY
|
Facility
|
OP
|
$198.53
|
|
|
Service Code
|
CPT 86215
|
| Hospital Charge Code |
3008621501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna of VT Commercial |
$188.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$87.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$119.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$160.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$89.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.83
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cigna Commercial |
$158.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$89.34
|
| Rate for Payer: Multiplan Commercial |
$184.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$89.34
|
| Rate for Payer: United Healthcare Commercial |
$188.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare VA CCN |
$89.34
|
|
|
DEOXYRIBONUCLEASE ANTIBODY
|
Facility
|
IP
|
$198.53
|
|
|
Service Code
|
CPT 86215
|
| Hospital Charge Code |
3008621501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.93 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna of VT Commercial |
$188.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$146.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$146.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$166.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$158.82
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cigna Commercial |
$158.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.82
|
| Rate for Payer: Multiplan Commercial |
$184.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$168.75
|
| Rate for Payer: United Healthcare Commercial |
$188.60
|
|
|
DEPO-TESTOSTERONE 200 MG/ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636J107102
|
|
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
|
|
|
DEPO-TESTOSTERONE 200 MG/ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636J107102
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.08
|
| 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 |
$0.08
|
| 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
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
5101727001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.64 |
| Max. Negotiated Rate |
$249.10 |
| Rate for Payer: Aetna of VT Commercial |
$249.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$128.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$105.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.59
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$102.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$143.04
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare Commercial |
$140.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare VA CCN |
$91.64
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$401.87 |
| Max. Negotiated Rate |
$515.85 |
| Rate for Payer: Aetna of VT Commercial |
$515.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$401.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$401.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$461.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$456.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$434.40
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$434.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$434.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$434.40
|
| Rate for Payer: Multiplan Commercial |
$504.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.55
|
| Rate for Payer: United Healthcare Commercial |
$515.85
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
5101727001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$117.37 |
| Max. Negotiated Rate |
$251.75 |
| Rate for Payer: Aetna of VT Commercial |
$251.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$117.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$237.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$159.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$119.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$210.68
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$119.25
|
| Rate for Payer: United Healthcare Commercial |
$251.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$119.25
|
| Rate for Payer: United Healthcare VA CCN |
$119.25
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$123.57 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna of VT Commercial |
$265.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$249.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$123.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$249.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$167.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$237.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$225.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$125.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$221.81
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$223.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$223.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$223.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$125.55
|
| Rate for Payer: Multiplan Commercial |
$259.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$237.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$125.55
|
| Rate for Payer: United Healthcare Commercial |
$265.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$125.55
|
| Rate for Payer: United Healthcare VA CCN |
$125.55
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$206.49 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna of VT Commercial |
$265.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$237.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$234.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$223.20
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$223.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$223.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$223.20
|
| Rate for Payer: Multiplan Commercial |
$259.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$237.15
|
| Rate for Payer: United Healthcare Commercial |
$265.05
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$240.49 |
| Max. Negotiated Rate |
$515.85 |
| Rate for Payer: Aetna of VT Commercial |
$515.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$240.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$326.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$461.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$439.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$244.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$431.69
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$434.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$434.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$434.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$244.35
|
| Rate for Payer: Multiplan Commercial |
$504.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$461.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$244.35
|
| Rate for Payer: United Healthcare Commercial |
$515.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$244.35
|
| Rate for Payer: United Healthcare VA CCN |
$244.35
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$91.64 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna of VT Commercial |
$262.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$249.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$249.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$128.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$105.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.59
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$102.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$143.04
|
| Rate for Payer: Multiplan Commercial |
$259.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare Commercial |
$140.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare VA CCN |
$91.64
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Professional
|
Both
|
$543.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
9601727001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$91.64 |
| Max. Negotiated Rate |
$510.42 |
| Rate for Payer: Aetna of VT Commercial |
$510.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$94.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$128.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$105.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.59
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$102.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$143.04
|
| Rate for Payer: Multiplan Commercial |
$504.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare Commercial |
$140.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.64
|
| Rate for Payer: United Healthcare VA CCN |
$91.64
|
|
|
DEST MAL LES S/N/H/F/G 0.5CM/>
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
CPT 17270
|
| Hospital Charge Code |
5101727001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$196.13 |
| Max. Negotiated Rate |
$251.75 |
| Rate for Payer: Aetna of VT Commercial |
$251.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$196.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$196.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$225.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$222.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$212.00
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$212.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$212.00
|
| Rate for Payer: Multiplan Commercial |
$246.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$225.25
|
| Rate for Payer: United Healthcare Commercial |
$251.75
|
|
|
DESTROY VAG LESIONS SIMPLE
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
CPT 57061
|
| Hospital Charge Code |
9825706101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$109.17 |
| Max. Negotiated Rate |
$263.20 |
| Rate for Payer: Aetna of VT Commercial |
$263.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$250.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$112.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$250.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$152.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$207.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$207.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$125.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$207.64
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$192.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$256.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$256.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.35
|
| Rate for Payer: Multiplan Commercial |
$260.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$155.02
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$109.17
|
| Rate for Payer: United Healthcare Commercial |
$167.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.17
|
| Rate for Payer: United Healthcare VA CCN |
$109.17
|
|
