|
EPINEPHRINE 10 MG/10 ML VIAL
|
Facility
|
IP
|
$12.37
|
|
|
Service Code
|
NDC 5428860001
|
| Hospital Charge Code |
636J017106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$11.75 |
| Rate for Payer: Aetna of VT Commercial |
$11.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$10.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.90
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$9.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.51
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
|
|
EPINEPHRINE 10 MG/10 ML VIAL
|
Facility
|
OP
|
$12.37
|
|
|
Service Code
|
NDC 5428860001
|
| Hospital Charge Code |
636J017106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$11.75 |
| Rate for Payer: Aetna of VT Commercial |
$11.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$11.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$11.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$7.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$10.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$5.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.83
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$9.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.57
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.57
|
| Rate for Payer: United Healthcare VA CCN |
$5.57
|
|
|
EPINEPHRINE 1 MG/10 ML ABBOJEC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
636J017102
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
EPINEPHRINE 1 MG/10 ML ABBOJEC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
636J017102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
EPINEPHRINE 30 MG/30 ML VIAL
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
636J017104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna of VT Commercial |
$4.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.54
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2.00
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.00
|
| Rate for Payer: United Healthcare VA CCN |
$2.00
|
|
|
EPINEPHRINE 30 MG/30 ML VIAL
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
636J017104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna of VT Commercial |
$4.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.56
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.56
|
| Rate for Payer: Multiplan Commercial |
$4.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.78
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
|
|
EPISIOTOMY OR VAGINAL REPAIR
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
CPT 59300
|
| Hospital Charge Code |
9695930001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$322.68 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Aetna of VT Commercial |
$414.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$322.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$322.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$370.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$366.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$348.80
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$348.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.80
|
| Rate for Payer: Multiplan Commercial |
$405.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$370.60
|
| Rate for Payer: United Healthcare Commercial |
$414.20
|
|
|
EPISIOTOMY OR VAGINAL REPAIR
|
Professional
|
Both
|
$436.00
|
|
|
Service Code
|
CPT 59300
|
| Hospital Charge Code |
9695930001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$132.10 |
| Max. Negotiated Rate |
$409.84 |
| Rate for Payer: Aetna of VT Commercial |
$409.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$390.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$136.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$390.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$184.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$305.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$305.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$151.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$305.25
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$144.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$351.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$351.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$208.87
|
| Rate for Payer: Multiplan Commercial |
$405.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$132.10
|
| Rate for Payer: United Healthcare Commercial |
$203.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.10
|
| Rate for Payer: United Healthcare VA CCN |
$132.10
|
|
|
EPISIOTOMY OR VAGINAL REPAIR
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
CPT 59300
|
| Hospital Charge Code |
9695930001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$193.10 |
| Max. Negotiated Rate |
$414.20 |
| Rate for Payer: Aetna of VT Commercial |
$414.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$390.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$193.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$390.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$262.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$370.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$353.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$346.62
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$348.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$348.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$348.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$196.20
|
| Rate for Payer: Multiplan Commercial |
$405.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$370.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$196.20
|
| Rate for Payer: United Healthcare Commercial |
$414.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$196.20
|
| Rate for Payer: United Healthcare VA CCN |
$196.20
|
|
|
EPSTEIN-BARR ANTIBODY
|
Professional
|
Both
|
$94.61
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
3008666301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$88.93 |
| Rate for Payer: Aetna of VT Commercial |
$88.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.42
|
| Rate for Payer: Cash Price |
$47.30
|
| Rate for Payer: Cash Price |
$47.30
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.94
|
| Rate for Payer: Multiplan Commercial |
$87.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$20.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.12
|
| Rate for Payer: United Healthcare VA CCN |
$13.12
|
|
|
EPSTEIN-BARR ANTIBODY
|
Facility
|
OP
|
$94.61
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
3008666301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$89.88 |
| Rate for Payer: Aetna of VT Commercial |
$89.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$56.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$75.21
|
| Rate for Payer: Cash Price |
$47.30
|
| Rate for Payer: Cash Price |
$47.30
|
| Rate for Payer: Cigna Commercial |
$75.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$75.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$75.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$42.57
|
| Rate for Payer: Multiplan Commercial |
$87.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$42.57
|
| Rate for Payer: United Healthcare Commercial |
$89.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.12
|
| Rate for Payer: United Healthcare VA CCN |
$42.57
|
|
|
EPSTEIN-BARR ANTIBODY
|
Facility
|
IP
|
$94.61
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
3008666301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.02 |
| Max. Negotiated Rate |
$89.88 |
| Rate for Payer: Aetna of VT Commercial |
$89.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$70.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$70.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$79.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$75.69
|
| Rate for Payer: Cash Price |
$47.30
|
| Rate for Payer: Cigna Commercial |
$75.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$75.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$75.69
|
| Rate for Payer: Multiplan Commercial |
$87.99
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.42
|
| Rate for Payer: United Healthcare Commercial |
$89.88
|
|
|
EPSTEIN-BARR CAPSID VCA
|
Facility
|
OP
|
$180.95
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
3008666501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$171.90 |
| Rate for Payer: Aetna of VT Commercial |
$171.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$80.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$108.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$153.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$146.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$81.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.86
|
| Rate for Payer: Cash Price |
$90.47
|
| Rate for Payer: Cash Price |
$90.47
|
| Rate for Payer: Cigna Commercial |
$144.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$144.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$144.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$81.43
|
| Rate for Payer: Multiplan Commercial |
$168.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$81.43
|
| Rate for Payer: United Healthcare Commercial |
$171.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.14
|
| Rate for Payer: United Healthcare VA CCN |
$81.43
|
|
|
EPSTEIN-BARR CAPSID VCA
|
Facility
|
IP
|
$180.95
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
3008666501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.92 |
| Max. Negotiated Rate |
$171.90 |
| Rate for Payer: Aetna of VT Commercial |
$171.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$133.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$133.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$153.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$144.76
|
| Rate for Payer: Cash Price |
$90.47
|
| Rate for Payer: Cigna Commercial |
$144.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$144.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$144.76
|
| Rate for Payer: Multiplan Commercial |
$168.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.81
|
| Rate for Payer: United Healthcare Commercial |
$171.90
|
|
|
EPSTEIN-BARR CAPSID VCA
|
Professional
|
Both
|
$180.95
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
3008666501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.89 |
| Max. Negotiated Rate |
$170.09 |
| Rate for Payer: Aetna of VT Commercial |
$170.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$31.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$31.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$31.01
|
| Rate for Payer: Cash Price |
$90.47
|
| Rate for Payer: Cash Price |
$90.47
|
| Rate for Payer: Cigna Commercial |
$21.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$18.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$18.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.89
|
| Rate for Payer: Multiplan Commercial |
$168.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.14
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$18.14
|
| Rate for Payer: United Healthcare Commercial |
$27.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.14
|
| Rate for Payer: United Healthcare VA CCN |
$18.14
|
|
|
EPSTEIN-BARR NUCLEAR ANTIGEN
|
Facility
|
OP
|
$132.69
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
3008666401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$126.06 |
| Rate for Payer: Aetna of VT Commercial |
$126.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$75.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$75.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.49
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.15
|
| Rate for Payer: Martins Point Health Care Commercial |
$59.71
|
| Rate for Payer: Multiplan Commercial |
$123.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$59.71
|
| Rate for Payer: United Healthcare Commercial |
$126.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare VA CCN |
$59.71
|
|
|
EPSTEIN-BARR NUCLEAR ANTIGEN
|
Facility
|
IP
|
$132.69
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
3008666401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.20 |
| Max. Negotiated Rate |
$126.06 |
| Rate for Payer: Aetna of VT Commercial |
$126.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.15
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.15
|
| Rate for Payer: Multiplan Commercial |
$123.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.79
|
| Rate for Payer: United Healthcare Commercial |
$126.06
|
|
|
EPSTEIN-BARR NUCLEAR ANTIGEN
|
Professional
|
Both
|
$132.69
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
3008666401
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$124.73 |
| Rate for Payer: Aetna of VT Commercial |
$124.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$75.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$75.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$21.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$26.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.14
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$18.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$15.08
|
| Rate for Payer: Multiplan Commercial |
$123.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare Commercial |
$23.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare VA CCN |
$15.29
|
|
|
ESCITALOPRAM 10 MG TABLET
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 904642661
|
| Hospital Charge Code |
2500000599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of VT Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.13
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna Commercial |
$0.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.14
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.07
|
| Rate for Payer: United Healthcare VA CCN |
$0.07
|
|
|
ESCITALOPRAM 10 MG TABLET
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 904642661
|
| Hospital Charge Code |
2500000599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of VT Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.13
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna Commercial |
$0.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
|
|
ESOPHAGOSCOPY FLEX REMOVE FB
|
Professional
|
Both
|
$745.00
|
|
|
Service Code
|
CPT 43215
|
| Hospital Charge Code |
9824321501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$130.11 |
| Max. Negotiated Rate |
$700.30 |
| Rate for Payer: Aetna of VT Commercial |
$700.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$667.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$134.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$667.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$182.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$685.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$685.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$149.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$685.24
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cigna Commercial |
$238.04
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$593.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$593.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$365.23
|
| Rate for Payer: Multiplan Commercial |
$692.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$184.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$130.11
|
| Rate for Payer: United Healthcare Commercial |
$200.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.11
|
| Rate for Payer: United Healthcare VA CCN |
$130.11
|
|
|
ESOPHAGOSCOPY FLEX REMOVE FB
|
Facility
|
IP
|
$745.00
|
|
|
Service Code
|
CPT 43215
|
| Hospital Charge Code |
9824321501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$551.37 |
| Max. Negotiated Rate |
$707.75 |
| Rate for Payer: Aetna of VT Commercial |
$707.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$551.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$551.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$633.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$625.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$596.00
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cigna Commercial |
$596.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$596.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$596.00
|
| Rate for Payer: Multiplan Commercial |
$692.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$633.25
|
| Rate for Payer: United Healthcare Commercial |
$707.75
|
|
|
ESOPHAGOSCOPY FLEX REMOVE FB
|
Facility
|
OP
|
$745.00
|
|
|
Service Code
|
CPT 43215
|
| Hospital Charge Code |
9824321501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$329.96 |
| Max. Negotiated Rate |
$707.75 |
| Rate for Payer: Aetna of VT Commercial |
$707.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$667.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$329.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$667.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$448.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$633.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$603.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$335.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$592.27
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cigna Commercial |
$596.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$596.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$596.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$692.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$633.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$335.25
|
| Rate for Payer: United Healthcare Commercial |
$707.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$335.25
|
| Rate for Payer: United Healthcare VA CCN |
$335.25
|
|
|
ESOPH EGD DILATION <30 MM
|
Facility
|
OP
|
$1,713.00
|
|
|
Service Code
|
CPT 43249
|
| Hospital Charge Code |
9824324901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$758.69 |
| Max. Negotiated Rate |
$1,627.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,627.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,534.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$758.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,534.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,031.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,456.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,387.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$770.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,361.84
|
| Rate for Payer: Cash Price |
$856.50
|
| Rate for Payer: Cigna Commercial |
$1,370.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,370.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,370.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$770.85
|
| Rate for Payer: Multiplan Commercial |
$1,593.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,456.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$770.85
|
| Rate for Payer: United Healthcare Commercial |
$1,627.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$770.85
|
| Rate for Payer: United Healthcare VA CCN |
$770.85
|
|
|
ESOPH EGD DILATION <30 MM
|
Professional
|
Both
|
$1,713.00
|
|
|
Service Code
|
CPT 43249
|
| Hospital Charge Code |
9824324901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$141.53 |
| Max. Negotiated Rate |
$1,827.40 |
| Rate for Payer: Aetna of VT Commercial |
$1,610.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,534.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,534.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$198.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,827.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,827.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$162.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,827.40
|
| Rate for Payer: Cash Price |
$856.50
|
| Rate for Payer: Cash Price |
$856.50
|
| Rate for Payer: Cigna Commercial |
$259.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,575.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,575.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$979.54
|
| Rate for Payer: Multiplan Commercial |
$1,593.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.53
|
| Rate for Payer: United Healthcare Commercial |
$217.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.53
|
| Rate for Payer: United Healthcare VA CCN |
$141.53
|
|
