|
FOOT LONGITUDINAL ARCH 1ST PR
|
Facility
|
OP
|
$361.90
|
|
|
Service Code
|
HCPCS L3010 50
|
| Hospital Charge Code |
274L301001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$160.29 |
| Max. Negotiated Rate |
$343.81 |
| Rate for Payer: Aetna of VT Commercial |
$343.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$324.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$160.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$324.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$217.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$307.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$293.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$162.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$287.71
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: Cigna Commercial |
$289.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$289.52
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$289.52
|
| Rate for Payer: Martins Point Health Care Commercial |
$162.85
|
| Rate for Payer: Multiplan Commercial |
$336.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$307.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$162.85
|
| Rate for Payer: United Healthcare Commercial |
$343.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$162.85
|
| Rate for Payer: United Healthcare VA CCN |
$162.85
|
|
|
FOOT LONGITUD/METATARSAL 2>PR
|
Facility
|
IP
|
$310.20
|
|
|
Service Code
|
HCPCS L3020 50
|
| Hospital Charge Code |
274L302001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$229.58 |
| Max. Negotiated Rate |
$294.69 |
| Rate for Payer: Aetna of VT Commercial |
$294.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$229.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$229.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$263.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$260.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$248.16
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$248.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$248.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$248.16
|
| Rate for Payer: Multiplan Commercial |
$288.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$263.67
|
| Rate for Payer: United Healthcare Commercial |
$294.69
|
|
|
FOOT LONGITUD/METATARSAL 2>PR
|
Facility
|
OP
|
$310.20
|
|
|
Service Code
|
HCPCS L3020 50
|
| Hospital Charge Code |
274L302001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$137.39 |
| Max. Negotiated Rate |
$294.69 |
| Rate for Payer: Aetna of VT Commercial |
$294.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$277.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$137.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$277.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$186.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$263.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$251.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$139.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$246.61
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$248.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$248.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$248.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$139.59
|
| Rate for Payer: Multiplan Commercial |
$288.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$263.67
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$139.59
|
| Rate for Payer: United Healthcare Commercial |
$294.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$139.59
|
| Rate for Payer: United Healthcare VA CCN |
$139.59
|
|
|
FOOT LONGITUD/METATARSAL 2>PR
|
Professional
|
Both
|
$310.20
|
|
|
Service Code
|
HCPCS L3020 50
|
| Hospital Charge Code |
274L302001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$124.08 |
| Max. Negotiated Rate |
$291.59 |
| Rate for Payer: Aetna of VT Commercial |
$291.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$277.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$277.91
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$233.30
|
| Rate for Payer: Multiplan Commercial |
$288.49
|
| Rate for Payer: United Healthcare Commercial |
$263.67
|
| Rate for Payer: United Healthcare VA CCN |
$124.08
|
|
|
FRAGMENTING OF KIDNEY STONE
|
Facility
|
OP
|
$2,608.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
9825059001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,155.08 |
| Max. Negotiated Rate |
$2,477.60 |
| Rate for Payer: Aetna of VT Commercial |
$2,477.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,336.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,155.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,336.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,570.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,216.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,112.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,173.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,073.36
|
| Rate for Payer: Cash Price |
$1,304.00
|
| Rate for Payer: Cigna Commercial |
$2,086.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,086.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,086.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,173.60
|
| Rate for Payer: Multiplan Commercial |
$2,425.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,216.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,173.60
|
| Rate for Payer: United Healthcare Commercial |
$2,477.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,173.60
|
| Rate for Payer: United Healthcare VA CCN |
$1,173.60
|
|
|
FRAGMENTING OF KIDNEY STONE
|
Facility
|
IP
|
$2,608.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
9825059001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,930.18 |
| Max. Negotiated Rate |
$2,477.60 |
| Rate for Payer: Aetna of VT Commercial |
$2,477.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,930.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,930.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,216.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,190.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,086.40
|
| Rate for Payer: Cash Price |
$1,304.00
|
| Rate for Payer: Cigna Commercial |
$2,086.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,086.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,086.40
|
| Rate for Payer: Multiplan Commercial |
$2,425.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,216.80
|
| Rate for Payer: United Healthcare Commercial |
$2,477.60
|
|
|
FRAGMENTING OF KIDNEY STONE
|
Professional
|
Both
|
$2,608.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
9825059001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$538.31 |
| Max. Negotiated Rate |
$2,451.52 |
| Rate for Payer: Aetna of VT Commercial |
$2,451.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,336.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$554.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,336.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$753.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,515.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,515.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$619.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,515.39
|
| Rate for Payer: Cash Price |
$1,304.00
|
| Rate for Payer: Cash Price |
$1,304.00
|
| Rate for Payer: Cigna Commercial |
$936.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,139.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,139.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$696.02
|
| Rate for Payer: Multiplan Commercial |
$2,425.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$764.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$538.31
|
| Rate for Payer: United Healthcare Commercial |
$828.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$538.31
|
| Rate for Payer: United Healthcare VA CCN |
$538.31
|
|
|
FREE ASSAY (FT-3)
|
Facility
|
IP
|
$242.71
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
3008448101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$179.63 |
| Max. Negotiated Rate |
$230.57 |
| Rate for Payer: Aetna of VT Commercial |
$230.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$179.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$179.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$206.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$203.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$194.17
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cigna Commercial |
$194.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$194.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$194.17
|
| Rate for Payer: Multiplan Commercial |
$225.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$206.30
|
| Rate for Payer: United Healthcare Commercial |
$230.57
|
|
|
FREE ASSAY (FT-3)
|
Professional
|
Both
|
$242.71
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
3008448101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$228.15 |
| Rate for Payer: Aetna of VT Commercial |
$228.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$28.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$28.95
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cigna Commercial |
$20.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$16.70
|
| Rate for Payer: Multiplan Commercial |
$225.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$16.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$16.94
|
| Rate for Payer: United Healthcare Commercial |
$26.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Healthcare VA CCN |
$16.94
|
|
|
FREE ASSAY (FT-3)
|
Facility
|
OP
|
$242.71
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
3008448101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.94 |
| Max. Negotiated Rate |
$230.57 |
| Rate for Payer: Aetna of VT Commercial |
$230.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$146.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$206.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$196.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$109.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$192.95
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cigna Commercial |
$194.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$194.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$194.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$109.22
|
| Rate for Payer: Multiplan Commercial |
$225.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$206.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$109.22
|
| Rate for Payer: United Healthcare Commercial |
$230.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Healthcare VA CCN |
$109.22
|
|
|
FREEING OF BOWEL ADHESION
|
Professional
|
Both
|
$4,085.00
|
|
|
Service Code
|
CPT 44005
|
| Hospital Charge Code |
9824400501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$992.70 |
| Max. Negotiated Rate |
$3,839.90 |
| Rate for Payer: Aetna of VT Commercial |
$3,839.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,659.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,022.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,659.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,389.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,601.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,601.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,141.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,601.95
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cigna Commercial |
$1,815.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,691.55
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,691.55
|
| Rate for Payer: Martins Point Health Care Commercial |
$992.70
|
| Rate for Payer: Multiplan Commercial |
$3,799.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,409.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$992.70
|
| Rate for Payer: United Healthcare Commercial |
$1,527.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$992.70
|
| Rate for Payer: United Healthcare VA CCN |
$992.70
|
|
|
FREEING OF BOWEL ADHESION
|
Facility
|
OP
|
$4,085.00
|
|
|
Service Code
|
CPT 44005
|
| Hospital Charge Code |
9824400501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,809.25 |
| Max. Negotiated Rate |
$3,880.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,880.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,659.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,809.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,659.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,459.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,472.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,308.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,838.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,247.57
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cigna Commercial |
$3,268.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,268.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,268.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,838.25
|
| Rate for Payer: Multiplan Commercial |
$3,799.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,472.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,838.25
|
| Rate for Payer: United Healthcare Commercial |
$3,880.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,838.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,838.25
|
|
|
FREEING OF BOWEL ADHESION
|
Facility
|
IP
|
$4,085.00
|
|
|
Service Code
|
CPT 44005
|
| Hospital Charge Code |
9824400501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$3,023.31 |
| Max. Negotiated Rate |
$3,880.75 |
| Rate for Payer: Aetna of VT Commercial |
$3,880.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,023.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,023.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,472.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,431.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,268.00
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cigna Commercial |
$3,268.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,268.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,268.00
|
| Rate for Payer: Multiplan Commercial |
$3,799.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,472.25
|
| Rate for Payer: United Healthcare Commercial |
$3,880.75
|
|
|
FT ARCH SUPRT PREMOLD LONGIT
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
274L304001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$39.23 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Aetna of VT Commercial |
$50.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$39.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$39.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$44.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$42.40
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$42.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$42.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$42.40
|
| Rate for Payer: Multiplan Commercial |
$49.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.05
|
| Rate for Payer: United Healthcare Commercial |
$50.35
|
|
|
FT ARCH SUPRT PREMOLD LONGIT
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
274L304001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$85.13 |
| Rate for Payer: Aetna of VT Commercial |
$49.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$57.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$77.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$63.64
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$44.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$44.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$55.34
|
| Rate for Payer: Multiplan Commercial |
$49.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$55.34
|
| Rate for Payer: United Healthcare Commercial |
$85.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.34
|
| Rate for Payer: United Healthcare VA CCN |
$55.34
|
|
|
FT ARCH SUPRT PREMOLD LONGIT
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
274L304001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Aetna of VT Commercial |
$50.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$42.13
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$42.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$42.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$42.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$23.85
|
| Rate for Payer: Multiplan Commercial |
$49.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$23.85
|
| Rate for Payer: United Healthcare Commercial |
$50.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.85
|
| Rate for Payer: United Healthcare VA CCN |
$23.85
|
|
|
FULVESTRANT 250 MG/5 ML *340B*
|
Professional
|
Both
|
$431.70
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
636J939502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.66 |
| Max. Negotiated Rate |
$405.80 |
| Rate for Payer: Aetna of VT Commercial |
$405.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.74
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.90
|
| Rate for Payer: Multiplan Commercial |
$401.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.73
|
| Rate for Payer: United Healthcare Commercial |
$10.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.73
|
| Rate for Payer: United Healthcare VA CCN |
$6.73
|
|
|
FULVESTRANT 250 MG/5 ML *340B*
|
Facility
|
OP
|
$18.98
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
636J939502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$18.98 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$18.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$18.98
|
|
|
FUNGUS ISOLATION CULTURE
|
Professional
|
Both
|
$143.73
|
|
|
Service Code
|
CPT 87102
|
| Hospital Charge Code |
3008710201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.29 |
| Max. Negotiated Rate |
$135.11 |
| Rate for Payer: Aetna of VT Commercial |
$135.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$41.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$41.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$11.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$11.56
|
| Rate for Payer: Cash Price |
$71.86
|
| Rate for Payer: Cash Price |
$71.86
|
| Rate for Payer: Cigna Commercial |
$10.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.41
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.41
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.29
|
| Rate for Payer: Multiplan Commercial |
$133.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.41
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.41
|
| Rate for Payer: United Healthcare Commercial |
$12.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.41
|
| Rate for Payer: United Healthcare VA CCN |
$8.41
|
|
|
FUNGUS ISOLATION CULTURE
|
Facility
|
IP
|
$143.73
|
|
|
Service Code
|
CPT 87102
|
| Hospital Charge Code |
3008710201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.37 |
| Max. Negotiated Rate |
$136.54 |
| Rate for Payer: Aetna of VT Commercial |
$136.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$122.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$120.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$114.98
|
| Rate for Payer: Cash Price |
$71.86
|
| Rate for Payer: Cigna Commercial |
$114.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$114.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$114.98
|
| Rate for Payer: Multiplan Commercial |
$133.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$122.17
|
| Rate for Payer: United Healthcare Commercial |
$136.54
|
|
|
FUNGUS ISOLATION CULTURE
|
Facility
|
OP
|
$143.73
|
|
|
Service Code
|
CPT 87102
|
| Hospital Charge Code |
3008710201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$136.54 |
| Rate for Payer: Aetna of VT Commercial |
$136.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$41.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$41.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$122.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$116.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$114.27
|
| Rate for Payer: Cash Price |
$71.86
|
| Rate for Payer: Cash Price |
$71.86
|
| Rate for Payer: Cigna Commercial |
$114.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$114.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$114.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$64.68
|
| Rate for Payer: Multiplan Commercial |
$133.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$122.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$64.68
|
| Rate for Payer: United Healthcare Commercial |
$136.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.41
|
| Rate for Payer: United Healthcare VA CCN |
$64.68
|
|
|
FUNGUS NES ANTIBODY
|
Professional
|
Both
|
$84.27
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
3008667101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.08 |
| Max. Negotiated Rate |
$79.21 |
| Rate for Payer: Aetna of VT Commercial |
$79.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$60.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$60.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$20.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.93
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cigna Commercial |
$14.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.08
|
| Rate for Payer: Multiplan Commercial |
$78.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.25
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.25
|
| Rate for Payer: United Healthcare VA CCN |
$12.25
|
|
|
FUNGUS NES ANTIBODY
|
Facility
|
IP
|
$84.27
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
3008667101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.37 |
| Max. Negotiated Rate |
$80.06 |
| Rate for Payer: Aetna of VT Commercial |
$80.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$70.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$67.42
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cigna Commercial |
$67.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$67.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$67.42
|
| Rate for Payer: Multiplan Commercial |
$78.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.63
|
| Rate for Payer: United Healthcare Commercial |
$80.06
|
|
|
FUNGUS NES ANTIBODY
|
Facility
|
OP
|
$84.27
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
3008667101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$80.06 |
| Rate for Payer: Aetna of VT Commercial |
$80.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$60.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$37.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$60.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$50.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$68.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$66.99
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cigna Commercial |
$67.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$67.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$67.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.92
|
| Rate for Payer: Multiplan Commercial |
$78.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.92
|
| Rate for Payer: United Healthcare Commercial |
$80.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.25
|
| Rate for Payer: United Healthcare VA CCN |
$37.92
|
|
|
FUROSEMIDE 100MG/10ML VIAL
|
Facility
|
OP
|
$6.41
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
636J193803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Aetna of VT Commercial |
$6.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5.10
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna Commercial |
$5.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$5.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2.88
|
| Rate for Payer: United Healthcare Commercial |
$6.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.88
|
| Rate for Payer: United Healthcare VA CCN |
$2.88
|
|
