|
DRUG SCREEN QUANT ZONISAMIDE
|
Facility
|
OP
|
$212.29
|
|
|
Service Code
|
CPT 80203
|
| Hospital Charge Code |
3008020301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$201.68 |
| Rate for Payer: Aetna of VT Commercial |
$201.68
|
| 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 |
$94.02
|
| 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 |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$95.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.77
|
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Cigna Commercial |
$169.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.53
|
| Rate for Payer: Multiplan Commercial |
$197.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$95.53
|
| Rate for Payer: United Healthcare Commercial |
$201.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare VA CCN |
$95.53
|
|
|
DRUG SCREEN QUANT ZONISAMIDE
|
Facility
|
IP
|
$212.29
|
|
|
Service Code
|
CPT 80203
|
| Hospital Charge Code |
3008020301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$157.12 |
| Max. Negotiated Rate |
$201.68 |
| Rate for Payer: Aetna of VT Commercial |
$201.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$157.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$157.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.83
|
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Cigna Commercial |
$169.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.83
|
| Rate for Payer: Multiplan Commercial |
$197.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.45
|
| Rate for Payer: United Healthcare Commercial |
$201.68
|
|
|
DRUG SCRN QUAN LEVETIRACETAM
|
Facility
|
OP
|
$211.97
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
3008017701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$201.37 |
| Rate for Payer: Aetna of VT Commercial |
$201.37
|
| 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 |
$93.88
|
| 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 |
$127.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$95.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.52
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cigna Commercial |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.39
|
| Rate for Payer: Multiplan Commercial |
$197.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$95.39
|
| Rate for Payer: United Healthcare Commercial |
$201.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare VA CCN |
$95.39
|
|
|
DRUG SCRN QUAN LEVETIRACETAM
|
Facility
|
IP
|
$211.97
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
3008017701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.88 |
| Max. Negotiated Rate |
$201.37 |
| Rate for Payer: Aetna of VT Commercial |
$201.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.58
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cigna Commercial |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.58
|
| Rate for Payer: Multiplan Commercial |
$197.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.17
|
| Rate for Payer: United Healthcare Commercial |
$201.37
|
|
|
DRUG SCRN QUAN LEVETIRACETAM
|
Professional
|
Both
|
$211.97
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
3008017701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$199.25 |
| Rate for Payer: Aetna of VT Commercial |
$199.25
|
| 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 |
$105.98
|
| Rate for Payer: Cash Price |
$105.98
|
| 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 |
$197.13
|
| 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
|
|
|
DRUG/SUBSTANCE NOS 1-3
|
Facility
|
IP
|
$323.13
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
3008037501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$239.15 |
| Max. Negotiated Rate |
$306.97 |
| Rate for Payer: Aetna of VT Commercial |
$306.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$239.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$239.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$274.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$271.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$258.50
|
| Rate for Payer: Cash Price |
$161.56
|
| Rate for Payer: Cigna Commercial |
$258.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.50
|
| Rate for Payer: Multiplan Commercial |
$300.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$274.66
|
| Rate for Payer: United Healthcare Commercial |
$306.97
|
|
|
DRUG/SUBSTANCE NOS 1-3
|
Professional
|
Both
|
$323.13
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
3008037501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.53 |
| Max. Negotiated Rate |
$303.74 |
| Rate for Payer: Aetna of VT Commercial |
$303.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$38.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$38.59
|
| Rate for Payer: Cash Price |
$161.56
|
| Rate for Payer: Cash Price |
$161.56
|
| Rate for Payer: Cigna Commercial |
$29.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$21.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$21.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$83.85
|
| Rate for Payer: Multiplan Commercial |
$300.51
|
| Rate for Payer: United Healthcare Commercial |
$274.66
|
| Rate for Payer: United Healthcare VA CCN |
$129.25
|
|
|
DRUG/SUBSTANCE NOS 1-3
|
Facility
|
OP
|
$323.13
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
3008037501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.32 |
| Max. Negotiated Rate |
$306.97 |
| Rate for Payer: Aetna of VT Commercial |
$306.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$143.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$194.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$274.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$261.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$145.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$256.89
|
| Rate for Payer: Cash Price |
$161.56
|
| Rate for Payer: Cash Price |
$161.56
|
| Rate for Payer: Cigna Commercial |
$258.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$145.41
|
| Rate for Payer: Multiplan Commercial |
$300.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$274.66
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$145.41
|
| Rate for Payer: United Healthcare Commercial |
$306.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$145.41
|
| Rate for Payer: United Healthcare VA CCN |
$145.41
|
|
|
DRUG TEST DEF 1-7 CLASSES
|
Facility
|
IP
|
$208.35
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
300G048001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$154.20 |
| Max. Negotiated Rate |
$197.93 |
| Rate for Payer: Aetna of VT Commercial |
$197.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$175.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$166.68
|
| Rate for Payer: Cash Price |
$104.17
|
| Rate for Payer: Cigna Commercial |
$166.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$166.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$166.68
|
| Rate for Payer: Multiplan Commercial |
$193.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.10
|
| Rate for Payer: United Healthcare Commercial |
$197.93
|
|
|
DRUG TEST DEF 1-7 CLASSES
|
Facility
|
OP
|
$208.35
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
300G048001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.28 |
| Max. Negotiated Rate |
$563.85 |
| Rate for Payer: Aetna of VT Commercial |
$197.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$563.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$92.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$563.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$125.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$168.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$93.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.64
|
| Rate for Payer: Cash Price |
$104.17
|
| Rate for Payer: Cash Price |
$104.17
|
| Rate for Payer: Cigna Commercial |
$166.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$166.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$166.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.76
|
| Rate for Payer: Multiplan Commercial |
$193.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$93.76
|
| Rate for Payer: United Healthcare Commercial |
$197.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.43
|
| Rate for Payer: United Healthcare VA CCN |
$93.76
|
|
|
DRUG TEST DEF 1-7 CLASSES
|
Professional
|
Both
|
$208.35
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
300G048001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.83 |
| Max. Negotiated Rate |
$563.85 |
| Rate for Payer: Aetna of VT Commercial |
$195.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$563.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$117.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$563.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$160.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$148.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$148.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$131.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$148.37
|
| Rate for Payer: Cash Price |
$104.17
|
| Rate for Payer: Cash Price |
$104.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$158.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$158.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.83
|
| Rate for Payer: Multiplan Commercial |
$193.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$162.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$114.43
|
| Rate for Payer: United Healthcare Commercial |
$176.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.43
|
| Rate for Payer: United Healthcare VA CCN |
$114.43
|
|
|
DRUG TEST PRSMV CHEM ANLYZR
|
Facility
|
OP
|
$211.97
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
3008030701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$306.19 |
| Rate for Payer: Aetna of VT Commercial |
$201.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$93.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$95.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.52
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cigna Commercial |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.39
|
| Rate for Payer: Multiplan Commercial |
$197.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$95.39
|
| Rate for Payer: United Healthcare Commercial |
$201.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Healthcare VA CCN |
$95.39
|
|
|
DRUG TEST PRSMV CHEM ANLYZR
|
Facility
|
IP
|
$211.97
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
3008030701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.88 |
| Max. Negotiated Rate |
$201.37 |
| Rate for Payer: Aetna of VT Commercial |
$201.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.58
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cigna Commercial |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.58
|
| Rate for Payer: Multiplan Commercial |
$197.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.17
|
| Rate for Payer: United Healthcare Commercial |
$201.37
|
|
|
DRUG TEST PRSMV CHEM ANLYZR
|
Professional
|
Both
|
$211.97
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
3008030701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.27 |
| Max. Negotiated Rate |
$306.19 |
| Rate for Payer: Aetna of VT Commercial |
$199.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$64.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$87.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$85.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$85.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$85.35
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cash Price |
$105.98
|
| Rate for Payer: Cigna Commercial |
$75.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$62.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$62.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.27
|
| Rate for Payer: Multiplan Commercial |
$197.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.14
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.14
|
| Rate for Payer: United Healthcare Commercial |
$95.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.14
|
| Rate for Payer: United Healthcare VA CCN |
$62.14
|
|
|
DRUG TEST PRSMV DIR OPT OBS
|
Professional
|
Both
|
$51.46
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
3008030501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.42 |
| Max. Negotiated Rate |
$62.09 |
| Rate for Payer: Aetna of VT Commercial |
$48.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$17.31
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cigna Commercial |
$15.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.42
|
| Rate for Payer: Multiplan Commercial |
$47.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.60
|
| Rate for Payer: United Healthcare Commercial |
$19.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.60
|
| Rate for Payer: United Healthcare VA CCN |
$12.60
|
|
|
DRUG TEST PRSMV DIR OPT OBS
|
Facility
|
IP
|
$51.46
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
3008030501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.09 |
| Max. Negotiated Rate |
$48.89 |
| Rate for Payer: Aetna of VT Commercial |
$48.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$38.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$38.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$43.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$43.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$41.17
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cigna Commercial |
$41.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$41.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$41.17
|
| Rate for Payer: Multiplan Commercial |
$47.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$43.74
|
| Rate for Payer: United Healthcare Commercial |
$48.89
|
|
|
DRUG TEST PRSMV DIR OPT OBS
|
Facility
|
OP
|
$51.46
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
3008030501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$62.09 |
| Rate for Payer: Aetna of VT Commercial |
$48.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$22.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$43.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$23.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$40.91
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cash Price |
$25.73
|
| Rate for Payer: Cigna Commercial |
$41.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$41.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$41.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$23.16
|
| Rate for Payer: Multiplan Commercial |
$47.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$43.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$23.16
|
| Rate for Payer: United Healthcare Commercial |
$48.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.60
|
| Rate for Payer: United Healthcare VA CCN |
$23.16
|
|
|
DRUG TEST PRSMV INSTRMNT
|
Professional
|
Both
|
$140.62
|
|
|
Service Code
|
CPT 80306
|
| Hospital Charge Code |
3008030601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$132.18 |
| Rate for Payer: Aetna of VT Commercial |
$132.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$23.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.54
|
| Rate for Payer: Cash Price |
$70.31
|
| Rate for Payer: Cash Price |
$70.31
|
| Rate for Payer: Cigna Commercial |
$20.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$16.90
|
| Rate for Payer: Multiplan Commercial |
$130.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.14
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.14
|
| Rate for Payer: United Healthcare Commercial |
$26.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.14
|
| Rate for Payer: United Healthcare VA CCN |
$17.14
|
|
|
DRUG TEST PRSMV INSTRMNT
|
Facility
|
OP
|
$140.62
|
|
|
Service Code
|
CPT 80306
|
| Hospital Charge Code |
3008030601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.14 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Aetna of VT Commercial |
$133.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$84.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$63.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$111.79
|
| Rate for Payer: Cash Price |
$70.31
|
| Rate for Payer: Cash Price |
$70.31
|
| Rate for Payer: Cigna Commercial |
$112.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$112.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$112.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$63.28
|
| Rate for Payer: Multiplan Commercial |
$130.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$119.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$63.28
|
| Rate for Payer: United Healthcare Commercial |
$133.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.14
|
| Rate for Payer: United Healthcare VA CCN |
$63.28
|
|
|
DRUG TEST PRSMV INSTRMNT
|
Facility
|
IP
|
$140.62
|
|
|
Service Code
|
CPT 80306
|
| Hospital Charge Code |
3008030601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.07 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Aetna of VT Commercial |
$133.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$118.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$112.50
|
| Rate for Payer: Cash Price |
$70.31
|
| Rate for Payer: Cigna Commercial |
$112.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$112.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$130.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$119.53
|
| Rate for Payer: United Healthcare Commercial |
$133.59
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
9604690002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$131.19 |
| Max. Negotiated Rate |
$429.58 |
| Rate for Payer: Aetna of VT Commercial |
$429.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$409.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$135.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$409.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$183.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$315.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$315.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$150.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$315.80
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cigna Commercial |
$238.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$375.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$375.44
|
| Rate for Payer: Martins Point Health Care Commercial |
$230.76
|
| Rate for Payer: Multiplan Commercial |
$425.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$186.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$131.19
|
| Rate for Payer: United Healthcare Commercial |
$201.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.19
|
| Rate for Payer: United Healthcare VA CCN |
$131.19
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
9604690002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$202.41 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Aetna of VT Commercial |
$434.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$409.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$202.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$409.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$275.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$388.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$370.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$205.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$363.31
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cigna Commercial |
$365.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$365.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$365.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$205.65
|
| Rate for Payer: Multiplan Commercial |
$425.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$388.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$205.65
|
| Rate for Payer: United Healthcare Commercial |
$434.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$205.65
|
| Rate for Payer: United Healthcare VA CCN |
$205.65
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Facility
|
IP
|
$925.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
9604690001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$684.59 |
| Max. Negotiated Rate |
$878.75 |
| Rate for Payer: Aetna of VT Commercial |
$878.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$684.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$684.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$786.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$777.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$740.00
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$740.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$740.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$740.00
|
| Rate for Payer: Multiplan Commercial |
$860.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$786.25
|
| Rate for Payer: United Healthcare Commercial |
$878.75
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
9604690002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$338.23 |
| Max. Negotiated Rate |
$434.15 |
| Rate for Payer: Aetna of VT Commercial |
$434.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$338.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$338.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$388.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$383.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$365.60
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cigna Commercial |
$365.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$365.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$365.60
|
| Rate for Payer: Multiplan Commercial |
$425.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$388.45
|
| Rate for Payer: United Healthcare Commercial |
$434.15
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Facility
|
OP
|
$925.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
9604690001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$409.68 |
| Max. Negotiated Rate |
$878.75 |
| Rate for Payer: Aetna of VT Commercial |
$878.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$828.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$409.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$828.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$556.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$786.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$749.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$416.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$735.38
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$740.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$740.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$740.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$416.25
|
| Rate for Payer: Multiplan Commercial |
$860.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$786.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$416.25
|
| Rate for Payer: United Healthcare Commercial |
$878.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$416.25
|
| Rate for Payer: United Healthcare VA CCN |
$416.25
|
|
