|
ESOPH EGD DILATION <30 MM
|
Facility
|
IP
|
$1,713.00
|
|
|
Service Code
|
CPT 43249
|
| Hospital Charge Code |
9824324901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,267.79 |
| 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 |
$1,267.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,267.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,456.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,438.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,370.40
|
| 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: Multiplan Commercial |
$1,593.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,456.05
|
| Rate for Payer: United Healthcare Commercial |
$1,627.35
|
|
|
ESTRADIOL VALERATE PROLIA 1 MG
|
Professional
|
Both
|
$155.83
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna of VT Commercial |
$146.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$10.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.34
|
| Rate for Payer: Cash Price |
$77.92
|
| Rate for Payer: Cash Price |
$77.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.30
|
| Rate for Payer: Multiplan Commercial |
$144.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.25
|
| Rate for Payer: United Healthcare Commercial |
$11.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.25
|
| Rate for Payer: United Healthcare VA CCN |
$7.25
|
|
|
ESTRADIOL VALERATE PROLIA 1 MG
|
Facility
|
OP
|
$155.83
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.08 |
| Max. Negotiated Rate |
$148.04 |
| Rate for Payer: Aetna of VT Commercial |
$148.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$93.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$70.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$123.88
|
| Rate for Payer: Cash Price |
$77.92
|
| Rate for Payer: Cash Price |
$77.92
|
| Rate for Payer: Cigna Commercial |
$124.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.12
|
| Rate for Payer: Multiplan Commercial |
$144.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$132.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$70.12
|
| Rate for Payer: United Healthcare Commercial |
$148.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.12
|
| Rate for Payer: United Healthcare VA CCN |
$70.12
|
|
|
ESTRADIOL VALERATE PROLIA 1 MG
|
Facility
|
IP
|
$155.83
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$148.04 |
| Rate for Payer: Aetna of VT Commercial |
$148.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$115.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$115.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$130.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$124.66
|
| Rate for Payer: Cash Price |
$77.92
|
| Rate for Payer: Cigna Commercial |
$124.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.66
|
| Rate for Payer: Multiplan Commercial |
$144.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$132.46
|
| Rate for Payer: United Healthcare Commercial |
$148.04
|
|
|
ESTRADIOL VALERATE XGEVA 1 MG
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.13 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna of VT Commercial |
$131.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$117.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$115.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$110.40
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$110.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$128.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$117.30
|
| Rate for Payer: United Healthcare Commercial |
$131.10
|
|
|
ESTRADIOL VALERATE XGEVA 1 MG
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna of VT Commercial |
$129.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$10.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.34
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.30
|
| Rate for Payer: Multiplan Commercial |
$128.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.25
|
| Rate for Payer: United Healthcare Commercial |
$11.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.25
|
| Rate for Payer: United Healthcare VA CCN |
$7.25
|
|
|
ESTRADIOL VALERATE XGEVA 1 MG
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636J138002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.08 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna of VT Commercial |
$131.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$61.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$83.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$117.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$62.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$109.71
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$110.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$110.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$62.10
|
| Rate for Payer: Multiplan Commercial |
$128.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$117.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.10
|
| Rate for Payer: United Healthcare Commercial |
$131.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.10
|
| Rate for Payer: United Healthcare VA CCN |
$62.10
|
|
|
ESTROGEN RECEPTOR
|
Professional
|
Both
|
$437.38
|
|
|
Service Code
|
CPT 88360
|
| Hospital Charge Code |
3008836002
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$114.55 |
| Max. Negotiated Rate |
$411.14 |
| Rate for Payer: Aetna of VT Commercial |
$411.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$388.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$117.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$388.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$160.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$171.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$131.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$171.93
|
| Rate for Payer: Cash Price |
$218.69
|
| Rate for Payer: Cash Price |
$218.69
|
| Rate for Payer: Cigna Commercial |
$154.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$114.56
|
| Rate for Payer: Multiplan Commercial |
$406.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$114.55
|
| Rate for Payer: United Healthcare Commercial |
$176.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.55
|
| Rate for Payer: United Healthcare VA CCN |
$114.55
|
|
|
ESTROGEN RECEPTOR
|
Facility
|
IP
|
$437.38
|
|
|
Service Code
|
CPT 88360
|
| Hospital Charge Code |
3008836002
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$323.70 |
| Max. Negotiated Rate |
$415.51 |
| Rate for Payer: Aetna of VT Commercial |
$415.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$323.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$323.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$371.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$367.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$349.90
|
| Rate for Payer: Cash Price |
$218.69
|
| Rate for Payer: Cigna Commercial |
$349.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$349.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$349.90
|
| Rate for Payer: Multiplan Commercial |
$406.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$371.77
|
| Rate for Payer: United Healthcare Commercial |
$415.51
|
|
|
ESTROGEN RECEPTOR
|
Facility
|
OP
|
$437.38
|
|
|
Service Code
|
CPT 88360
|
| Hospital Charge Code |
3008836002
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$114.55 |
| Max. Negotiated Rate |
$415.51 |
| Rate for Payer: Aetna of VT Commercial |
$415.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$388.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$193.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$388.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$263.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$371.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$354.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$196.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$347.72
|
| Rate for Payer: Cash Price |
$218.69
|
| Rate for Payer: Cash Price |
$218.69
|
| Rate for Payer: Cigna Commercial |
$349.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$349.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$349.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$196.82
|
| Rate for Payer: Multiplan Commercial |
$406.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$371.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$196.82
|
| Rate for Payer: United Healthcare Commercial |
$415.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.55
|
| Rate for Payer: United Healthcare VA CCN |
$196.82
|
|
|
ESW MUSCSKEL SYS NOS
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T02
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$1,482.88 |
| Rate for Payer: Aetna of VT Commercial |
$93.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,482.88
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$212.97
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T01
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$59.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$78.70
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.55
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare VA CCN |
$44.55
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T02
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.27 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.20
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T02
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$59.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$78.70
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.55
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.55
|
| Rate for Payer: United Healthcare VA CCN |
$44.55
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T01
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.27 |
| Max. Negotiated Rate |
$94.05 |
| Rate for Payer: Aetna of VT Commercial |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.20
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.15
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
|
|
ESW MUSCSKEL SYS NOS
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
5100101T01
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$1,482.88 |
| Rate for Payer: Aetna of VT Commercial |
$93.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,482.88
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$212.97
|
|
|
ESW MUSCSKEL SYS NOS
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
9600101T01
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$1,482.88 |
| Rate for Payer: Aetna of VT Commercial |
$93.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.69
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,482.88
|
| Rate for Payer: Multiplan Commercial |
$92.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$212.97
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
5100101T01
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.08 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna of VT Commercial |
$90.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$42.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$85.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$57.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$75.53
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$88.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$42.75
|
| Rate for Payer: United Healthcare Commercial |
$90.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.75
|
| Rate for Payer: United Healthcare VA CCN |
$42.75
|
|
|
ESW MUSCSKEL SYS NOS
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
CPT 0101T
|
| Hospital Charge Code |
5100101T01
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna of VT Commercial |
$90.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$79.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$76.00
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$88.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.75
|
| Rate for Payer: United Healthcare Commercial |
$90.25
|
|
|
ETCO2 FILT NASAL SAMP CANNULA
|
Facility
|
OP
|
$10.17
|
|
| Hospital Charge Code |
2700074721
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Aetna of VT Commercial |
$9.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$6.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.09
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4.58
|
| Rate for Payer: United Healthcare Commercial |
$9.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.58
|
| Rate for Payer: United Healthcare VA CCN |
$4.58
|
|
|
ETCO2 FILT NASAL SAMP CANNULA
|
Facility
|
IP
|
$10.17
|
|
| Hospital Charge Code |
2700074721
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Aetna of VT Commercial |
$9.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.14
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.14
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.64
|
| Rate for Payer: United Healthcare Commercial |
$9.66
|
|
|
ETHYL CHLORIDE 116 ML
|
Professional
|
Both
|
$27.03
|
|
|
Service Code
|
NDC 386000102
|
| Hospital Charge Code |
2500000112
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.81 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna of VT Commercial |
$25.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.22
|
| Rate for Payer: Cash Price |
$13.52
|
| Rate for Payer: Multiplan Commercial |
$25.14
|
| Rate for Payer: United Healthcare Commercial |
$22.98
|
| Rate for Payer: United Healthcare VA CCN |
$10.81
|
|
|
ETHYL CHLORIDE 116 ML
|
Professional
|
Both
|
$27.03
|
|
| Hospital Charge Code |
2500000112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.81 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna of VT Commercial |
$25.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.22
|
| Rate for Payer: Cash Price |
$13.52
|
| Rate for Payer: Multiplan Commercial |
$25.14
|
| Rate for Payer: United Healthcare Commercial |
$22.98
|
| Rate for Payer: United Healthcare VA CCN |
$10.81
|
|
|
EVACUATE MOLE OF UTERUS
|
Professional
|
Both
|
$1,388.00
|
|
|
Service Code
|
CPT 59870
|
| Hospital Charge Code |
9605987002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$490.94 |
| Max. Negotiated Rate |
$1,304.72 |
| Rate for Payer: Aetna of VT Commercial |
$1,304.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,243.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$505.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,243.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$687.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$702.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$702.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$564.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$702.97
|
| Rate for Payer: Cash Price |
$694.00
|
| Rate for Payer: Cash Price |
$694.00
|
| Rate for Payer: Cigna Commercial |
$542.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$490.94
|
| Rate for Payer: Multiplan Commercial |
$1,290.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$697.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$490.94
|
| Rate for Payer: United Healthcare Commercial |
$755.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$490.94
|
| Rate for Payer: United Healthcare VA CCN |
$490.94
|
|
|
EVACUATE MOLE OF UTERUS
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
CPT 59870
|
| Hospital Charge Code |
5105987001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$490.94 |
| Max. Negotiated Rate |
$832.66 |
| Rate for Payer: Aetna of VT Commercial |
$526.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$501.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$505.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$501.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$687.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$702.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$702.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$564.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$702.97
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$542.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$832.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$832.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$490.94
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$697.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$490.94
|
| Rate for Payer: United Healthcare Commercial |
$755.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$490.94
|
| Rate for Payer: United Healthcare VA CCN |
$490.94
|
|
