|
DILATION OF URETHRA
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT 53661
|
| Hospital Charge Code |
5105366101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.81 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of VT Commercial |
$119.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$112.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$55.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$112.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$75.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$107.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$100.17
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$100.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$100.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$100.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$56.70
|
| Rate for Payer: Multiplan Commercial |
$117.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$107.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$56.70
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.70
|
| Rate for Payer: United Healthcare VA CCN |
$56.70
|
|
|
DILATION OF URETHRA
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 53661
|
| Hospital Charge Code |
9605366102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$37.48 |
| Max. Negotiated Rate |
$175.78 |
| Rate for Payer: Aetna of VT Commercial |
$175.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$167.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$148.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$148.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.35
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$65.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$115.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$115.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.89
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.22
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.48
|
| Rate for Payer: United Healthcare Commercial |
$57.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.48
|
| Rate for Payer: United Healthcare VA CCN |
$37.48
|
|
|
DILATION OF URETHRA
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 53661
|
| Hospital Charge Code |
9605366102
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$138.40 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna of VT Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$149.60
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.60
|
| Rate for Payer: Multiplan Commercial |
$173.91
|
| Rate for Payer: MVP Health Care of NY Commercial |
$158.95
|
| Rate for Payer: United Healthcare Commercial |
$177.65
|
|
|
DIPHENHYDRAMINE 12.5MG/5ML SOL
|
Professional
|
Both
|
$0.03
|
|
|
Service Code
|
NDC 9999999937
|
| Hospital Charge Code |
2500000515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
DIPHENHYDRAMINE 12.5MG/5ML SOL
|
Professional
|
Both
|
$0.03
|
|
| Hospital Charge Code |
2500000515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
DIPHENHYDRAMINE 50 MG/ML VIAL
|
Facility
|
OP
|
$1.82
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636J120002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.82
|
|
|
DIPHENHYDRAMINE 50 MG/ML VIAL
|
Professional
|
Both
|
$3.27
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
636J120002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Aetna of VT Commercial |
$3.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.87
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.76
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.76
|
| Rate for Payer: United Healthcare VA CCN |
$0.76
|
|
|
DIPROPYLACETIC ACID FREE
|
Facility
|
IP
|
$29.07
|
|
|
Service Code
|
CPT 80165
|
| Hospital Charge Code |
3008016501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.51 |
| Max. Negotiated Rate |
$27.62 |
| Rate for Payer: Aetna of VT Commercial |
$27.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$21.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$21.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.26
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cigna Commercial |
$23.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.26
|
| Rate for Payer: Multiplan Commercial |
$27.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.71
|
| Rate for Payer: United Healthcare Commercial |
$27.62
|
|
|
DIPROPYLACETIC ACID FREE
|
Facility
|
OP
|
$29.07
|
|
|
Service Code
|
CPT 80165
|
| Hospital Charge Code |
3008016501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$66.72 |
| Rate for Payer: Aetna of VT Commercial |
$27.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.11
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cigna Commercial |
$23.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.08
|
| Rate for Payer: Multiplan Commercial |
$27.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.08
|
| Rate for Payer: United Healthcare Commercial |
$27.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.54
|
| Rate for Payer: United Healthcare VA CCN |
$13.08
|
|
|
DIPROPYLACETIC ACID FREE
|
Professional
|
Both
|
$29.07
|
|
|
Service Code
|
CPT 80165
|
| Hospital Charge Code |
3008016501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$66.72 |
| Rate for Payer: Aetna of VT Commercial |
$27.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.57
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cigna Commercial |
$16.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.35
|
| Rate for Payer: Multiplan Commercial |
$27.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.54
|
| Rate for Payer: United Healthcare Commercial |
$20.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.54
|
| Rate for Payer: United Healthcare VA CCN |
$13.54
|
|
|
DISPOSABLE KIT, KNEE FIBER TAK
|
Facility
|
OP
|
$427.00
|
|
| Hospital Charge Code |
2720074711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$189.12 |
| Max. Negotiated Rate |
$405.65 |
| Rate for Payer: Aetna of VT Commercial |
$405.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$382.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$189.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$382.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$257.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$362.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$345.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$192.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.46
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: Cigna Commercial |
$341.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$341.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$341.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$192.15
|
| Rate for Payer: Multiplan Commercial |
$397.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$362.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$192.15
|
| Rate for Payer: United Healthcare Commercial |
$405.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$192.15
|
| Rate for Payer: United Healthcare VA CCN |
$192.15
|
|
|
DISPOSABLE KIT, KNEE FIBER TAK
|
Facility
|
IP
|
$427.00
|
|
| Hospital Charge Code |
2720074711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.02 |
| Max. Negotiated Rate |
$405.65 |
| Rate for Payer: Aetna of VT Commercial |
$405.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$316.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$316.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$362.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$358.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$341.60
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: Cigna Commercial |
$341.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$341.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$341.60
|
| Rate for Payer: Multiplan Commercial |
$397.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$362.95
|
| Rate for Payer: United Healthcare Commercial |
$405.65
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$498.39
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
4809297701
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$368.86 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$418.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$398.71
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$132.26 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.26
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$118.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$86.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$86.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.66
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.66
|
| Rate for Payer: United Healthcare Commercial |
$79.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.66
|
| Rate for Payer: United Healthcare VA CCN |
$51.66
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$498.39
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
4509297701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$368.86 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$418.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$398.71
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
IP
|
$594.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$439.62 |
| Max. Negotiated Rate |
$564.30 |
| Rate for Payer: Aetna of VT Commercial |
$564.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$439.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$439.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$504.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$498.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$475.20
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$475.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$475.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$475.20
|
| Rate for Payer: Multiplan Commercial |
$552.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$504.90
|
| Rate for Payer: United Healthcare Commercial |
$564.30
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Professional
|
Both
|
$594.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$51.66 |
| Max. Negotiated Rate |
$558.36 |
| Rate for Payer: Aetna of VT Commercial |
$558.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$532.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$532.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.26
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$118.37
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$86.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$86.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.66
|
| Rate for Payer: Multiplan Commercial |
$552.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.66
|
| Rate for Payer: United Healthcare Commercial |
$79.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.66
|
| Rate for Payer: United Healthcare VA CCN |
$51.66
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$594.00
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
9819297702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$263.08 |
| Max. Negotiated Rate |
$564.30 |
| Rate for Payer: Aetna of VT Commercial |
$564.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$532.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$263.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$532.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$357.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$504.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$481.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$267.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$472.23
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$475.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$475.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$475.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$267.30
|
| Rate for Payer: Multiplan Commercial |
$552.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$504.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$267.30
|
| Rate for Payer: United Healthcare Commercial |
$564.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$267.30
|
| Rate for Payer: United Healthcare VA CCN |
$267.30
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$498.39
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
4809297701
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$220.74 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$300.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$403.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$224.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$396.22
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$224.28
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare VA CCN |
$224.28
|
|
|
DISSOLVE CLOT HEART VESSEL
|
Facility
|
OP
|
$498.39
|
|
|
Service Code
|
CPT 92977
|
| Hospital Charge Code |
4509297701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$220.74 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$300.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$403.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$224.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$396.22
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$224.28
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare VA CCN |
$224.28
|
|
|
DIVISION OF FALLOPIAN TUBE
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
CPT 58605
|
| Hospital Charge Code |
9825860501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$777.11 |
| Max. Negotiated Rate |
$997.50 |
| Rate for Payer: Aetna of VT Commercial |
$997.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$777.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$777.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$892.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$882.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$840.00
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$840.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$840.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$840.00
|
| Rate for Payer: Multiplan Commercial |
$976.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$892.50
|
| Rate for Payer: United Healthcare Commercial |
$997.50
|
|
|
DIVISION OF FALLOPIAN TUBE
|
Professional
|
Both
|
$1,050.00
|
|
|
Service Code
|
CPT 58605
|
| Hospital Charge Code |
9825860501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$314.34 |
| Max. Negotiated Rate |
$987.00 |
| Rate for Payer: Aetna of VT Commercial |
$987.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$940.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$323.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$940.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$440.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$558.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$558.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$361.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$558.06
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$556.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$523.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$523.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$322.38
|
| Rate for Payer: Multiplan Commercial |
$976.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$446.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$314.34
|
| Rate for Payer: United Healthcare Commercial |
$483.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$314.34
|
| Rate for Payer: United Healthcare VA CCN |
$314.34
|
|
|
DIVISION OF FALLOPIAN TUBE
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
CPT 58605
|
| Hospital Charge Code |
9825860501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$465.05 |
| Max. Negotiated Rate |
$997.50 |
| Rate for Payer: Aetna of VT Commercial |
$997.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$940.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$465.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$940.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$632.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$892.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$850.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$472.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$834.75
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$840.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$840.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$840.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$472.50
|
| Rate for Payer: Multiplan Commercial |
$976.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$892.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$472.50
|
| Rate for Payer: United Healthcare Commercial |
$997.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$472.50
|
| Rate for Payer: United Healthcare VA CCN |
$472.50
|
|
