|
EMERGENCY DEPT VISIT SF MDM
|
Facility
|
IP
|
$326.74
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
4509928201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$241.82 |
| Max. Negotiated Rate |
$310.40 |
| Rate for Payer: Aetna of VT Commercial |
$310.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$277.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$274.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$261.39
|
| Rate for Payer: Cash Price |
$163.37
|
| Rate for Payer: Cigna Commercial |
$261.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$261.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$261.39
|
| Rate for Payer: Multiplan Commercial |
$303.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$277.73
|
| Rate for Payer: United Healthcare Commercial |
$310.40
|
|
|
EMERGENCY DEPT VISIT SF MDM
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
9819928202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna of VT Commercial |
$182.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$142.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$142.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$161.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$153.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$153.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$153.60
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$163.20
|
| Rate for Payer: United Healthcare Commercial |
$182.40
|
|
|
EMERGENCY DEPT VISIT SF MDM
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
9819928202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$38.82 |
| Max. Negotiated Rate |
$180.48 |
| Rate for Payer: Aetna of VT Commercial |
$180.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.61
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$41.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.82
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.82
|
| Rate for Payer: United Healthcare Commercial |
$59.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.82
|
| Rate for Payer: United Healthcare VA CCN |
$38.82
|
|
|
EMERGENCY DEPT VISIT SF MDM
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
9819928201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$38.82 |
| Max. Negotiated Rate |
$180.48 |
| Rate for Payer: Aetna of VT Commercial |
$180.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.61
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$41.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.82
|
| Rate for Payer: Multiplan Commercial |
$178.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.82
|
| Rate for Payer: United Healthcare Commercial |
$59.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.82
|
| Rate for Payer: United Healthcare VA CCN |
$38.82
|
|
|
EMPAGLIFLOZIN 25 MG
|
Facility
|
IP
|
$62.10
|
|
|
Service Code
|
NDC 597015337
|
| Hospital Charge Code |
2500000588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.96 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna of VT Commercial |
$58.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$45.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$45.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$52.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.68
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$57.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.78
|
| Rate for Payer: United Healthcare Commercial |
$58.99
|
|
|
EMPAGLIFLOZIN 25 MG
|
Facility
|
IP
|
$62.10
|
|
| Hospital Charge Code |
2500000588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.96 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna of VT Commercial |
$58.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$45.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$45.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$52.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.68
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$57.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.78
|
| Rate for Payer: United Healthcare Commercial |
$58.99
|
|
|
EMPAGLIFLOZIN 25 MG
|
Facility
|
OP
|
$62.10
|
|
| Hospital Charge Code |
2500000588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna of VT Commercial |
$58.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$37.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.37
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.95
|
| Rate for Payer: Multiplan Commercial |
$57.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.95
|
| Rate for Payer: United Healthcare Commercial |
$58.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.95
|
| Rate for Payer: United Healthcare VA CCN |
$27.95
|
|
|
EMPAGLIFLOZIN 25 MG
|
Facility
|
OP
|
$62.10
|
|
|
Service Code
|
NDC 597015337
|
| Hospital Charge Code |
2500000588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.50 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna of VT Commercial |
$58.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$37.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.37
|
| Rate for Payer: Cash Price |
$31.05
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.95
|
| Rate for Payer: Multiplan Commercial |
$57.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.95
|
| Rate for Payer: United Healthcare Commercial |
$58.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.95
|
| Rate for Payer: United Healthcare VA CCN |
$27.95
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928101
|
|
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
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928101
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$30.31 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$30.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$30.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$14.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$29.28
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$11.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.52
|
| Rate for Payer: United Healthcare Commercial |
$16.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.52
|
| Rate for Payer: United Healthcare VA CCN |
$10.52
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Aetna of VT Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$123.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$121.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$116.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$116.00
|
| Rate for Payer: Multiplan Commercial |
$134.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$123.25
|
| Rate for Payer: United Healthcare Commercial |
$137.75
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$10.52 |
| Max. Negotiated Rate |
$136.30 |
| Rate for Payer: Aetna of VT Commercial |
$136.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$30.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$30.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$14.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$29.28
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$11.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$134.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.52
|
| Rate for Payer: United Healthcare Commercial |
$16.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.52
|
| Rate for Payer: United Healthcare VA CCN |
$10.52
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928102
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$64.22 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Aetna of VT Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$129.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$64.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$129.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$87.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$123.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$117.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$65.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$115.28
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$116.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$134.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$123.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$65.25
|
| Rate for Payer: United Healthcare Commercial |
$137.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.25
|
| Rate for Payer: United Healthcare VA CCN |
$65.25
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
9819928101
|
|
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
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
OP
|
$282.26
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
4509928101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.01 |
| Max. Negotiated Rate |
$268.15 |
| Rate for Payer: Aetna of VT Commercial |
$268.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$252.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$125.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$252.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$239.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$228.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$127.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$224.40
|
| Rate for Payer: Cash Price |
$141.13
|
| Rate for Payer: Cigna Commercial |
$225.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$225.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$225.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.02
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$239.92
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$127.02
|
| Rate for Payer: United Healthcare Commercial |
$268.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.02
|
| Rate for Payer: United Healthcare VA CCN |
$127.02
|
|
|
EMR DPT VST MAYX REQ PHY/QHP
|
Facility
|
IP
|
$282.26
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
4509928101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$208.90 |
| Max. Negotiated Rate |
$268.15 |
| Rate for Payer: Aetna of VT Commercial |
$268.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$208.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$208.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$239.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$237.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$225.81
|
| Rate for Payer: Cash Price |
$141.13
|
| Rate for Payer: Cigna Commercial |
$225.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$225.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$225.81
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$239.92
|
| Rate for Payer: United Healthcare Commercial |
$268.15
|
|
|
ENCEPHALITIS CALIFORN ANTBDY
|
Professional
|
Both
|
$417.00
|
|
|
Service Code
|
CPT 86651
|
| Hospital Charge Code |
3008665101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$391.98 |
| Rate for Payer: Aetna of VT Commercial |
$391.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.55
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.01
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare Commercial |
$20.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$13.19
|
|
|
ENCEPHALITIS CALIFORN ANTBDY
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
CPT 86651
|
| Hospital Charge Code |
3008665101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$308.62 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna of VT Commercial |
$396.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$308.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$308.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$350.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$333.60
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.60
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.45
|
| Rate for Payer: United Healthcare Commercial |
$396.15
|
|
|
ENCEPHALITIS CALIFORN ANTBDY
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
CPT 86651
|
| Hospital Charge Code |
3008665101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna of VT Commercial |
$396.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$184.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$251.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$354.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$337.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$187.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.51
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$333.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$333.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.65
|
| Rate for Payer: Multiplan Commercial |
$387.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$354.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$187.65
|
| Rate for Payer: United Healthcare Commercial |
$396.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$187.65
|
|
|
ENCEPHALTIS EAST EQNE ANBDY
|
Facility
|
OP
|
$309.17
|
|
|
Service Code
|
CPT 86652
|
| Hospital Charge Code |
3008665201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$293.71 |
| Rate for Payer: Aetna of VT Commercial |
$293.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$136.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$186.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$262.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$250.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$139.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$245.79
|
| Rate for Payer: Cash Price |
$154.58
|
| Rate for Payer: Cash Price |
$154.58
|
| Rate for Payer: Cigna Commercial |
$247.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$139.13
|
| Rate for Payer: Multiplan Commercial |
$287.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$262.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$139.13
|
| Rate for Payer: United Healthcare Commercial |
$293.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$139.13
|
|
|
ENCEPHALTIS EAST EQNE ANBDY
|
Professional
|
Both
|
$309.17
|
|
|
Service Code
|
CPT 86652
|
| Hospital Charge Code |
3008665201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$290.62 |
| Rate for Payer: Aetna of VT Commercial |
$290.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.55
|
| Rate for Payer: Cash Price |
$154.58
|
| Rate for Payer: Cash Price |
$154.58
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.01
|
| Rate for Payer: Multiplan Commercial |
$287.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare Commercial |
$20.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$13.19
|
|
|
ENCEPHALTIS EAST EQNE ANBDY
|
Facility
|
IP
|
$309.17
|
|
|
Service Code
|
CPT 86652
|
| Hospital Charge Code |
3008665201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$228.82 |
| Max. Negotiated Rate |
$293.71 |
| Rate for Payer: Aetna of VT Commercial |
$293.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$228.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$228.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$262.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$259.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$247.34
|
| Rate for Payer: Cash Price |
$154.58
|
| Rate for Payer: Cigna Commercial |
$247.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.34
|
| Rate for Payer: Multiplan Commercial |
$287.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$262.79
|
| Rate for Payer: United Healthcare Commercial |
$293.71
|
|
|
ENCEPHALTIS ST LOUIS ANTBODY
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
CPT 86653
|
| Hospital Charge Code |
3008665301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$465.50 |
| Rate for Payer: Aetna of VT Commercial |
$465.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$217.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$294.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$416.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$396.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$389.55
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$392.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$392.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$392.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$220.50
|
| Rate for Payer: Multiplan Commercial |
$455.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$416.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$220.50
|
| Rate for Payer: United Healthcare Commercial |
$465.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$220.50
|
|
|
ENCEPHALTIS ST LOUIS ANTBODY
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
CPT 86653
|
| Hospital Charge Code |
3008665301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$460.60 |
| Rate for Payer: Aetna of VT Commercial |
$460.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.55
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.01
|
| Rate for Payer: Multiplan Commercial |
$455.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare Commercial |
$20.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$13.19
|
|
|
ENCEPHALTIS ST LOUIS ANTBODY
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
CPT 86653
|
| Hospital Charge Code |
3008665301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$362.65 |
| Max. Negotiated Rate |
$465.50 |
| Rate for Payer: Aetna of VT Commercial |
$465.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$362.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$362.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$416.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$411.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$392.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$392.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$392.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$392.00
|
| Rate for Payer: Multiplan Commercial |
$455.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$416.50
|
| Rate for Payer: United Healthcare Commercial |
$465.50
|
|
