|
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
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
5104690001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$131.19 |
| Max. Negotiated Rate |
$439.92 |
| Rate for Payer: Aetna of VT Commercial |
$439.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$419.28
|
| 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 |
$419.28
|
| 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 |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| 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 |
$435.24
|
| 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
|
$468.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
5104690001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.28 |
| Max. Negotiated Rate |
$444.60 |
| Rate for Payer: Aetna of VT Commercial |
$444.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$419.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$207.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$419.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$281.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$379.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$210.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$372.06
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$374.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$374.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$374.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$210.60
|
| Rate for Payer: Multiplan Commercial |
$435.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$397.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$210.60
|
| Rate for Payer: United Healthcare Commercial |
$444.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.60
|
| Rate for Payer: United Healthcare VA CCN |
$210.60
|
|
|
DSTRJ LESION ANUS SIMPLE CHEM
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
CPT 46900
|
| Hospital Charge Code |
5104690001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$346.37 |
| Max. Negotiated Rate |
$444.60 |
| Rate for Payer: Aetna of VT Commercial |
$444.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$346.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$346.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$393.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$374.40
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$374.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$374.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$374.40
|
| Rate for Payer: Multiplan Commercial |
$435.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$397.80
|
| Rate for Payer: United Healthcare Commercial |
$444.60
|
|
|
DTAP-IPV/HIB VACCINE IM
|
Professional
|
Both
|
$238.05
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
6369069801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.09 |
| Max. Negotiated Rate |
$330.17 |
| Rate for Payer: Aetna of VT Commercial |
$223.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$330.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$330.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$93.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$93.09
|
| Rate for Payer: Cash Price |
$119.03
|
| Rate for Payer: Cash Price |
$119.03
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$161.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$161.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.27
|
| Rate for Payer: Multiplan Commercial |
$221.39
|
| Rate for Payer: United Healthcare Commercial |
$202.34
|
| Rate for Payer: United Healthcare VA CCN |
$122.00
|
|
|
DULOXETINE 20MG CAPSULE
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 5199174690
|
| Hospital Charge Code |
2500000592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of VT Commercial |
$0.96
|
| 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 |
$0.45
|
| 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 |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.82
|
| 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 |
$0.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
DULOXETINE 20MG CAPSULE
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 5199174690
|
| Hospital Charge Code |
2500000592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of VT Commercial |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.81
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
|
|
DUP-SCAN XTR VEINS CMPLT BILAT
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9729397001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$89.28 |
| Max. Negotiated Rate |
$677.47 |
| Rate for Payer: Aetna of VT Commercial |
$90.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.13
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$370.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.98
|
| Rate for Payer: Multiplan Commercial |
$89.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$248.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare Commercial |
$383.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare VA CCN |
$248.98
|
|
|
DUP-SCAN XTR VEINS CMPLT BILAT
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
CPT 93970
|
| Hospital Charge Code |
9729397001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna of VT Commercial |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$71.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$71.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$81.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$76.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$76.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.80
|
| Rate for Payer: Multiplan Commercial |
$89.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$81.60
|
| Rate for Payer: United Healthcare Commercial |
$91.20
|
|
|
DUP-SCAN XTR VEINS CMPLT BILAT
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
CPT 93970
|
| Hospital Charge Code |
9729397001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$42.52 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna of VT Commercial |
$91.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$86.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$42.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$86.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$57.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$81.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$77.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$76.32
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$76.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$43.20
|
| Rate for Payer: Multiplan Commercial |
$89.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$81.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$43.20
|
| Rate for Payer: United Healthcare Commercial |
$91.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.20
|
| Rate for Payer: United Healthcare VA CCN |
$43.20
|
|
|
DUP-SCAN XTR VEINS UNILATERAL
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 93971
|
| Hospital Charge Code |
9729397101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$268.66 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna of VT Commercial |
$344.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$268.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$268.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$308.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$304.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$290.40
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Cigna Commercial |
$290.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$290.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$290.40
|
| Rate for Payer: Multiplan Commercial |
$337.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$308.55
|
| Rate for Payer: United Healthcare Commercial |
$344.85
|
|
|
DUP-SCAN XTR VEINS UNILATERAL
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
CPT 93971
|
| Hospital Charge Code |
9729397101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$160.77 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna of VT Commercial |
$344.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$325.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$160.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$325.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$218.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$308.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$294.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$163.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$288.58
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Cigna Commercial |
$290.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$290.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$290.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$163.35
|
| Rate for Payer: Multiplan Commercial |
$337.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$308.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$163.35
|
| Rate for Payer: United Healthcare Commercial |
$344.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$163.35
|
| Rate for Payer: United Healthcare VA CCN |
$163.35
|
|
|
DUP-SCAN XTR VEINS UNILATERAL
|
Professional
|
Both
|
$363.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9729397101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$248.98 |
| Max. Negotiated Rate |
$677.47 |
| Rate for Payer: Aetna of VT Commercial |
$341.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.13
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Cash Price |
$181.50
|
| Rate for Payer: Cigna Commercial |
$370.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.98
|
| Rate for Payer: Multiplan Commercial |
$337.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$248.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare Commercial |
$383.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare VA CCN |
$248.98
|
|
|
DUROLANE (HYALURONATE) 60 MG
|
Facility
|
OP
|
$1,012.53
|
|
|
Service Code
|
NDC 8913020201
|
| Hospital Charge Code |
636J731801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$448.45 |
| Max. Negotiated Rate |
$961.90 |
| Rate for Payer: Aetna of VT Commercial |
$961.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$907.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$448.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$907.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$609.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$860.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$820.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$455.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$804.96
|
| Rate for Payer: Cash Price |
$506.26
|
| Rate for Payer: Cigna Commercial |
$810.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$810.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$810.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$455.64
|
| Rate for Payer: Multiplan Commercial |
$941.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$860.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$455.64
|
| Rate for Payer: United Healthcare Commercial |
$961.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$455.64
|
| Rate for Payer: United Healthcare VA CCN |
$455.64
|
|
|
DUROLANE (HYALURONATE) 60 MG
|
Facility
|
IP
|
$1,012.53
|
|
|
Service Code
|
NDC 8913020201
|
| Hospital Charge Code |
636J731801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$749.37 |
| Max. Negotiated Rate |
$961.90 |
| Rate for Payer: Aetna of VT Commercial |
$961.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$749.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$749.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$860.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$850.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$810.02
|
| Rate for Payer: Cash Price |
$506.26
|
| Rate for Payer: Cigna Commercial |
$810.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$810.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$810.02
|
| Rate for Payer: Multiplan Commercial |
$941.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$860.65
|
| Rate for Payer: United Healthcare Commercial |
$961.90
|
|
|
DUROLANE (HYALURONATE) 60 MG
|
Professional
|
Both
|
$1,012.53
|
|
|
Service Code
|
NDC 8913020201
|
| Hospital Charge Code |
636J731801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$405.01 |
| Max. Negotiated Rate |
$951.78 |
| Rate for Payer: Aetna of VT Commercial |
$951.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$907.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$907.13
|
| Rate for Payer: Cash Price |
$506.26
|
| Rate for Payer: Multiplan Commercial |
$941.65
|
| Rate for Payer: United Healthcare Commercial |
$860.65
|
| Rate for Payer: United Healthcare VA CCN |
$405.01
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9823152401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$199.83 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna of VT Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$199.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$199.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$229.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$226.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.00
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$229.50
|
| Rate for Payer: United Healthcare Commercial |
$256.50
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
OP
|
$729.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9813162401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$322.87 |
| Max. Negotiated Rate |
$692.55 |
| Rate for Payer: Aetna of VT Commercial |
$692.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$322.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$438.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$619.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$590.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$328.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$579.55
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna Commercial |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$583.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$328.05
|
| Rate for Payer: Multiplan Commercial |
$677.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$619.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$328.05
|
| Rate for Payer: United Healthcare Commercial |
$692.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$328.05
|
| Rate for Payer: United Healthcare VA CCN |
$328.05
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9823152401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$119.58 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna of VT Commercial |
$256.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$119.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$229.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$218.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.65
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$216.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$216.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$121.50
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$229.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$121.50
|
| Rate for Payer: United Healthcare Commercial |
$256.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.50
|
| Rate for Payer: United Healthcare VA CCN |
$121.50
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
IP
|
$1,766.07
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
4503162401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,307.07 |
| Max. Negotiated Rate |
$1,677.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,677.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,307.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,307.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,501.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,483.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,412.86
|
| Rate for Payer: Cash Price |
$883.04
|
| Rate for Payer: Cigna Commercial |
$1,412.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,412.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,412.86
|
| Rate for Payer: Multiplan Commercial |
$1,642.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,501.16
|
| Rate for Payer: United Healthcare Commercial |
$1,677.77
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Professional
|
Both
|
$729.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9813162401
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$123.46 |
| Max. Negotiated Rate |
$685.26 |
| Rate for Payer: Aetna of VT Commercial |
$685.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$172.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$411.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$411.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.44
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna Commercial |
$196.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.44
|
| Rate for Payer: Martins Point Health Care Commercial |
$242.63
|
| Rate for Payer: Multiplan Commercial |
$677.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$123.46
|
| Rate for Payer: United Healthcare Commercial |
$189.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$123.46
|
| Rate for Payer: United Healthcare VA CCN |
$123.46
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9823152401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$123.46 |
| Max. Negotiated Rate |
$411.44 |
| Rate for Payer: Aetna of VT Commercial |
$253.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$172.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$411.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$411.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.44
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$196.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.44
|
| Rate for Payer: Martins Point Health Care Commercial |
$242.63
|
| Rate for Payer: Multiplan Commercial |
$251.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$123.46
|
| Rate for Payer: United Healthcare Commercial |
$189.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$123.46
|
| Rate for Payer: United Healthcare VA CCN |
$123.46
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
OP
|
$1,766.07
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
4503162401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$782.19 |
| Max. Negotiated Rate |
$1,677.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,677.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,582.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$782.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,582.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,063.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,501.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,430.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$794.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,404.03
|
| Rate for Payer: Cash Price |
$883.04
|
| Rate for Payer: Cigna Commercial |
$1,412.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,412.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,412.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$794.73
|
| Rate for Payer: Multiplan Commercial |
$1,642.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,501.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$794.73
|
| Rate for Payer: United Healthcare Commercial |
$1,677.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$794.73
|
| Rate for Payer: United Healthcare VA CCN |
$794.73
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
OP
|
$729.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9813162402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$322.87 |
| Max. Negotiated Rate |
$692.55 |
| Rate for Payer: Aetna of VT Commercial |
$692.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$322.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$653.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$438.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$619.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$590.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$328.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$579.55
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna Commercial |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$583.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$328.05
|
| Rate for Payer: Multiplan Commercial |
$677.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$619.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$328.05
|
| Rate for Payer: United Healthcare Commercial |
$692.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$328.05
|
| Rate for Payer: United Healthcare VA CCN |
$328.05
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Facility
|
IP
|
$729.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
9813162402
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$539.53 |
| Max. Negotiated Rate |
$692.55 |
| Rate for Payer: Aetna of VT Commercial |
$692.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$539.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$539.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$619.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$612.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$583.20
|
| Rate for Payer: Cash Price |
$364.50
|
| Rate for Payer: Cigna Commercial |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$583.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$583.20
|
| Rate for Payer: Multiplan Commercial |
$677.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$619.65
|
| Rate for Payer: United Healthcare Commercial |
$692.55
|
|
