|
FUSION OF FOOT BONES
|
Facility
|
IP
|
$2,763.00
|
|
|
Service Code
|
CPT 28725
|
| Hospital Charge Code |
9822872501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$2,044.90 |
| Max. Negotiated Rate |
$2,624.85 |
| Rate for Payer: Aetna of VT Commercial |
$2,624.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,044.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,044.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,348.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,320.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,210.40
|
| Rate for Payer: Cash Price |
$1,381.50
|
| Rate for Payer: Cigna Commercial |
$2,210.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,210.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,210.40
|
| Rate for Payer: Multiplan Commercial |
$2,569.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,348.55
|
| Rate for Payer: United Healthcare Commercial |
$2,624.85
|
|
|
FUSION OF FOOT BONES
|
Professional
|
Both
|
$1,571.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
5102873001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$687.36 |
| Max. Negotiated Rate |
$1,476.74 |
| Rate for Payer: Aetna of VT Commercial |
$1,476.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,407.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$707.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,407.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$962.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,429.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,429.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$790.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,429.13
|
| Rate for Payer: Cash Price |
$785.50
|
| Rate for Payer: Cash Price |
$785.50
|
| Rate for Payer: Cigna Commercial |
$1,303.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,135.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,135.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$687.36
|
| Rate for Payer: Multiplan Commercial |
$1,461.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$976.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$687.36
|
| Rate for Payer: United Healthcare Commercial |
$1,057.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$687.36
|
| Rate for Payer: United Healthcare VA CCN |
$687.36
|
|
|
FUSION OF FOOT BONES
|
Facility
|
OP
|
$1,571.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
5102873001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$695.80 |
| Max. Negotiated Rate |
$1,492.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,492.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,407.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$695.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,407.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$945.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,335.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,272.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$706.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,248.94
|
| Rate for Payer: Cash Price |
$785.50
|
| Rate for Payer: Cigna Commercial |
$1,256.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,256.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,256.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$706.95
|
| Rate for Payer: Multiplan Commercial |
$1,461.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,335.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$706.95
|
| Rate for Payer: United Healthcare Commercial |
$1,492.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$706.95
|
| Rate for Payer: United Healthcare VA CCN |
$706.95
|
|
|
FUSION OF FOOT BONES
|
Facility
|
OP
|
$2,763.00
|
|
|
Service Code
|
CPT 28725
|
| Hospital Charge Code |
9822872501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,223.73 |
| Max. Negotiated Rate |
$2,624.85 |
| Rate for Payer: Aetna of VT Commercial |
$2,624.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,475.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,223.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,475.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,663.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,348.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,238.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,243.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,196.59
|
| Rate for Payer: Cash Price |
$1,381.50
|
| Rate for Payer: Cigna Commercial |
$2,210.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,210.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,210.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,243.35
|
| Rate for Payer: Multiplan Commercial |
$2,569.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,348.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,243.35
|
| Rate for Payer: United Healthcare Commercial |
$2,624.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,243.35
|
| Rate for Payer: United Healthcare VA CCN |
$1,243.35
|
|
|
FUSION OF FOOT BONES
|
Facility
|
OP
|
$2,337.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
9822873001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,035.06 |
| Max. Negotiated Rate |
$2,220.15 |
| Rate for Payer: Aetna of VT Commercial |
$2,220.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,093.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,035.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,093.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,406.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,986.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,892.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,051.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,857.91
|
| Rate for Payer: Cash Price |
$1,168.50
|
| Rate for Payer: Cigna Commercial |
$1,869.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,869.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,869.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,051.65
|
| Rate for Payer: Multiplan Commercial |
$2,173.41
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,986.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,051.65
|
| Rate for Payer: United Healthcare Commercial |
$2,220.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,051.65
|
| Rate for Payer: United Healthcare VA CCN |
$1,051.65
|
|
|
FUSION OF FOOT BONES
|
Professional
|
Both
|
$2,323.00
|
|
|
Service Code
|
CPT 28740
|
| Hospital Charge Code |
9822874001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$584.67 |
| Max. Negotiated Rate |
$2,183.62 |
| Rate for Payer: Aetna of VT Commercial |
$2,183.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,081.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$602.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,081.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$818.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,383.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,383.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$672.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,383.07
|
| Rate for Payer: Cash Price |
$1,161.50
|
| Rate for Payer: Cash Price |
$1,161.50
|
| Rate for Payer: Cigna Commercial |
$1,111.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,272.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,272.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$777.72
|
| Rate for Payer: Multiplan Commercial |
$2,160.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$830.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$584.67
|
| Rate for Payer: United Healthcare Commercial |
$899.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$584.67
|
| Rate for Payer: United Healthcare VA CCN |
$584.67
|
|
|
FUSION OF FOOT BONES
|
Facility
|
OP
|
$3,908.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
9602873001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,730.85 |
| Max. Negotiated Rate |
$3,712.60 |
| Rate for Payer: Aetna of VT Commercial |
$3,712.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,501.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,730.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,501.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,352.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,321.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,165.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,758.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,106.86
|
| Rate for Payer: Cash Price |
$1,954.00
|
| Rate for Payer: Cigna Commercial |
$3,126.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,126.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,126.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,758.60
|
| Rate for Payer: Multiplan Commercial |
$3,634.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,321.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,758.60
|
| Rate for Payer: United Healthcare Commercial |
$3,712.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,758.60
|
| Rate for Payer: United Healthcare VA CCN |
$1,758.60
|
|
|
FUSION OF FOOT BONES
|
Facility
|
IP
|
$1,571.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
5102873001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,162.70 |
| Max. Negotiated Rate |
$1,492.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,492.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,162.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,162.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,335.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,319.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,256.80
|
| Rate for Payer: Cash Price |
$785.50
|
| Rate for Payer: Cigna Commercial |
$1,256.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,256.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,256.80
|
| Rate for Payer: Multiplan Commercial |
$1,461.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,335.35
|
| Rate for Payer: United Healthcare Commercial |
$1,492.45
|
|
|
FUSION OF FOOT BONES
|
Professional
|
Both
|
$2,763.00
|
|
|
Service Code
|
CPT 28725
|
| Hospital Charge Code |
9822872501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$736.94 |
| Max. Negotiated Rate |
$2,597.22 |
| Rate for Payer: Aetna of VT Commercial |
$2,597.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,475.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$759.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,475.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,031.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,309.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,309.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$847.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,309.29
|
| Rate for Payer: Cash Price |
$1,381.50
|
| Rate for Payer: Cash Price |
$1,381.50
|
| Rate for Payer: Cigna Commercial |
$1,396.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,220.44
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,220.44
|
| Rate for Payer: Martins Point Health Care Commercial |
$736.94
|
| Rate for Payer: Multiplan Commercial |
$2,569.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,046.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$736.94
|
| Rate for Payer: United Healthcare Commercial |
$1,133.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$736.94
|
| Rate for Payer: United Healthcare VA CCN |
$736.94
|
|
|
GA67 GALLIUM
|
Facility
|
IP
|
$466.64
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
343A955601
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$345.36 |
| Max. Negotiated Rate |
$443.31 |
| Rate for Payer: Aetna of VT Commercial |
$443.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$345.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$345.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$396.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$391.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$373.31
|
| Rate for Payer: Cash Price |
$233.32
|
| Rate for Payer: Cigna Commercial |
$373.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$373.31
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$373.31
|
| Rate for Payer: Multiplan Commercial |
$433.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$396.64
|
| Rate for Payer: United Healthcare Commercial |
$443.31
|
|
|
GA67 GALLIUM
|
Facility
|
OP
|
$466.64
|
|
|
Service Code
|
HCPCS A9556
|
| Hospital Charge Code |
343A955601
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$206.67 |
| Max. Negotiated Rate |
$443.31 |
| Rate for Payer: Aetna of VT Commercial |
$443.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$418.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$206.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$418.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$280.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$396.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$377.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$209.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$370.98
|
| Rate for Payer: Cash Price |
$233.32
|
| Rate for Payer: Cigna Commercial |
$373.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$373.31
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$373.31
|
| Rate for Payer: Martins Point Health Care Commercial |
$209.99
|
| Rate for Payer: Multiplan Commercial |
$433.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$396.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$209.99
|
| Rate for Payer: United Healthcare Commercial |
$443.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$209.99
|
| Rate for Payer: United Healthcare VA CCN |
$209.99
|
|
|
GABAPENTIN NON-BLOOD
|
Facility
|
IP
|
$102.58
|
|
|
Service Code
|
CPT 80355
|
| Hospital Charge Code |
3008035501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$97.45 |
| Rate for Payer: Aetna of VT Commercial |
$97.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$75.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$75.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$86.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$82.06
|
| Rate for Payer: Cash Price |
$51.29
|
| Rate for Payer: Cigna Commercial |
$82.06
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$82.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$82.06
|
| Rate for Payer: Multiplan Commercial |
$95.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.19
|
| Rate for Payer: United Healthcare Commercial |
$97.45
|
|
|
GABAPENTIN NON-BLOOD
|
Facility
|
OP
|
$102.58
|
|
|
Service Code
|
CPT 80355
|
| Hospital Charge Code |
3008035501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$124.32 |
| Rate for Payer: Aetna of VT Commercial |
$97.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$45.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$61.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$46.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$81.55
|
| Rate for Payer: Cash Price |
$51.29
|
| Rate for Payer: Cash Price |
$51.29
|
| Rate for Payer: Cigna Commercial |
$82.06
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$82.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$82.06
|
| Rate for Payer: Martins Point Health Care Commercial |
$46.16
|
| Rate for Payer: Multiplan Commercial |
$95.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$46.16
|
| Rate for Payer: United Healthcare Commercial |
$97.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.16
|
| Rate for Payer: United Healthcare VA CCN |
$46.16
|
|
|
GABAPENTIN NON-BLOOD
|
Professional
|
Both
|
$102.58
|
|
|
Service Code
|
CPT 80355
|
| Hospital Charge Code |
3008035501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$124.32 |
| Rate for Payer: Aetna of VT Commercial |
$96.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Cash Price |
$51.29
|
| Rate for Payer: Cash Price |
$51.29
|
| Rate for Payer: Cigna Commercial |
$29.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.98
|
| Rate for Payer: Multiplan Commercial |
$95.40
|
| Rate for Payer: United Healthcare Commercial |
$87.19
|
| Rate for Payer: United Healthcare VA CCN |
$41.03
|
|
|
GAIT TRAINING THERAPY
|
Facility
|
OP
|
$118.29
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
4209711601
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.39 |
| Max. Negotiated Rate |
$112.38 |
| Rate for Payer: Aetna of VT Commercial |
$112.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$105.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$105.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$71.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$100.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$95.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.04
|
| Rate for Payer: Cash Price |
$59.15
|
| Rate for Payer: Cigna Commercial |
$94.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$94.63
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$94.63
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.23
|
| Rate for Payer: Multiplan Commercial |
$110.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.23
|
| Rate for Payer: United Healthcare Commercial |
$112.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.23
|
| Rate for Payer: United Healthcare VA CCN |
$53.23
|
|
|
GAIT TRAINING THERAPY
|
Facility
|
IP
|
$118.29
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
4209711601
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$87.55 |
| Max. Negotiated Rate |
$112.38 |
| Rate for Payer: Aetna of VT Commercial |
$112.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$87.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$87.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$100.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.63
|
| Rate for Payer: Cash Price |
$59.15
|
| Rate for Payer: Cigna Commercial |
$94.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$94.63
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$94.63
|
| Rate for Payer: Multiplan Commercial |
$110.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$100.55
|
| Rate for Payer: United Healthcare Commercial |
$112.38
|
|
|
GASES BLOOD PH ONLY
|
Facility
|
IP
|
$21.09
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
3008280001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.61 |
| Max. Negotiated Rate |
$20.04 |
| Rate for Payer: Aetna of VT Commercial |
$20.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$15.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$15.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.87
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cigna Commercial |
$16.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.87
|
| Rate for Payer: Multiplan Commercial |
$19.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.93
|
| Rate for Payer: United Healthcare Commercial |
$20.04
|
|
|
GASES BLOOD PH ONLY
|
Facility
|
OP
|
$21.09
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
3008280001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$54.20 |
| Rate for Payer: Aetna of VT Commercial |
$20.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$9.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$12.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$17.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.77
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cigna Commercial |
$16.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$16.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$16.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.49
|
| Rate for Payer: Multiplan Commercial |
$19.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.49
|
| Rate for Payer: United Healthcare Commercial |
$20.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.00
|
| Rate for Payer: United Healthcare VA CCN |
$9.49
|
|
|
GENERAL HEALTH PANEL
|
Professional
|
Both
|
$239.92
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3008005001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.81 |
| Max. Negotiated Rate |
$243.12 |
| Rate for Payer: Aetna of VT Commercial |
$225.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$243.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$243.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$72.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$72.32
|
| Rate for Payer: Cash Price |
$119.96
|
| Rate for Payer: Cash Price |
$119.96
|
| Rate for Payer: Cigna Commercial |
$48.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$44.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$44.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$62.83
|
| Rate for Payer: Multiplan Commercial |
$223.13
|
| Rate for Payer: United Healthcare Commercial |
$203.93
|
| Rate for Payer: United Healthcare VA CCN |
$95.97
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
IP
|
$239.92
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3008005001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$177.56 |
| Max. Negotiated Rate |
$227.92 |
| Rate for Payer: Aetna of VT Commercial |
$227.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$177.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$177.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$201.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$191.94
|
| Rate for Payer: Cash Price |
$119.96
|
| Rate for Payer: Cigna Commercial |
$191.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$191.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$191.94
|
| Rate for Payer: Multiplan Commercial |
$223.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.93
|
| Rate for Payer: United Healthcare Commercial |
$227.92
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
OP
|
$239.92
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3008005001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.26 |
| Max. Negotiated Rate |
$243.12 |
| Rate for Payer: Aetna of VT Commercial |
$227.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$243.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$106.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$243.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$203.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$194.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$107.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$190.74
|
| Rate for Payer: Cash Price |
$119.96
|
| Rate for Payer: Cash Price |
$119.96
|
| Rate for Payer: Cigna Commercial |
$191.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$191.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$191.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.96
|
| Rate for Payer: Multiplan Commercial |
$223.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$203.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$107.96
|
| Rate for Payer: United Healthcare Commercial |
$227.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.96
|
| Rate for Payer: United Healthcare VA CCN |
$107.96
|
|
|
GENTAMICIN 80 MG/2 ML (ADULT)
|
Facility
|
OP
|
$6.79
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636J158002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.79
|
|
|
GENTAMICIN 80 MG/2 ML (ADULT)
|
Professional
|
Both
|
$22.42
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
636J158002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$21.07 |
| Rate for Payer: Aetna of VT Commercial |
$21.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.54
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$2.47
|
| Rate for Payer: Multiplan Commercial |
$20.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2.21
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.21
|
| Rate for Payer: United Healthcare VA CCN |
$2.21
|
|
|
GIARDIA AG IA
|
Facility
|
OP
|
$566.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
3008732901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$537.70 |
| Rate for Payer: Aetna of VT Commercial |
$537.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$250.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$340.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$481.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$458.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$254.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$449.97
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cigna Commercial |
$452.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$452.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$452.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$254.70
|
| Rate for Payer: Multiplan Commercial |
$526.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$481.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$254.70
|
| Rate for Payer: United Healthcare Commercial |
$537.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare VA CCN |
$254.70
|
|
|
GIARDIA AG IA
|
Professional
|
Both
|
$566.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
3008732901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$532.04 |
| Rate for Payer: Aetna of VT Commercial |
$532.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$16.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$20.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$20.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$20.47
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cigna Commercial |
$14.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$11.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$11.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$11.81
|
| Rate for Payer: Multiplan Commercial |
$526.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare Commercial |
$18.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare VA CCN |
$11.98
|
|
