|
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
|
|
|
GLIDERITE SU STYLET LG
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2720054951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Aetna of VT Commercial |
$39.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$35.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$35.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.60
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$33.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$33.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$39.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$39.90
|
|
|
GLIDERITE SU STYLET LG
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2720054951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$39.90 |
| Rate for Payer: Aetna of VT Commercial |
$39.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$37.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$37.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$35.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.39
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$33.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$33.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$33.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$18.90
|
| Rate for Payer: Multiplan Commercial |
$39.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$18.90
|
| Rate for Payer: United Healthcare Commercial |
$39.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.90
|
| Rate for Payer: United Healthcare VA CCN |
$18.90
|
|
|
GLUCOSE BLOOD REAGENT STRIP
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3008294801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$24.83 |
| Rate for Payer: Aetna of VT Commercial |
$21.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$13.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$19.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$18.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$10.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$18.09
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$18.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$18.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$10.24
|
| Rate for Payer: Multiplan Commercial |
$21.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.34
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.24
|
| Rate for Payer: United Healthcare Commercial |
$21.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.04
|
| Rate for Payer: United Healthcare VA CCN |
$10.24
|
|
|
GLUCOSE BLOOD REAGENT STRIP
|
Facility
|
IP
|
$22.75
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3008294801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.84 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna of VT Commercial |
$21.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$19.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$19.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$18.20
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$18.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$18.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$18.20
|
| Rate for Payer: Multiplan Commercial |
$21.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.34
|
| Rate for Payer: United Healthcare Commercial |
$21.61
|
|
|
GLUCOSE BLOOD REAGENT STRIP
|
Professional
|
Both
|
$22.75
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3008294801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$24.83 |
| Rate for Payer: Aetna of VT Commercial |
$21.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$7.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$5.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.22
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna Commercial |
$5.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.04
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$21.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.04
|
| Rate for Payer: United Healthcare Commercial |
$7.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.04
|
| Rate for Payer: United Healthcare VA CCN |
$5.04
|
|
|
GLUCOSE BLOOD TEST
|
Facility
|
IP
|
$39.29
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
3008296201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.08 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of VT Commercial |
$37.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$33.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$31.43
|
| Rate for Payer: Cash Price |
$19.64
|
| Rate for Payer: Cigna Commercial |
$31.43
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.43
|
| Rate for Payer: Multiplan Commercial |
$36.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.40
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
|
|
GLUCOSE BLOOD TEST
|
Facility
|
OP
|
$39.29
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
3008296201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of VT Commercial |
$37.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$33.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$31.24
|
| Rate for Payer: Cash Price |
$19.64
|
| Rate for Payer: Cash Price |
$19.64
|
| Rate for Payer: Cigna Commercial |
$31.43
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.68
|
| Rate for Payer: Multiplan Commercial |
$36.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.68
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.28
|
| Rate for Payer: United Healthcare VA CCN |
$17.68
|
|
|
GLUCOSE OTHER FLUID
|
Facility
|
OP
|
$59.29
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
3008294501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$56.33 |
| Rate for Payer: Aetna of VT Commercial |
$56.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$19.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$26.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$19.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$35.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.14
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cigna Commercial |
$47.43
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$47.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$47.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$55.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$50.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.68
|
| Rate for Payer: United Healthcare Commercial |
$56.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.93
|
| Rate for Payer: United Healthcare VA CCN |
$26.68
|
|
|
GLUCOSE OTHER FLUID
|
Facility
|
IP
|
$59.29
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
3008294501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.88 |
| Max. Negotiated Rate |
$56.33 |
| Rate for Payer: Aetna of VT Commercial |
$56.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$43.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$43.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.43
|
| Rate for Payer: Cash Price |
$29.64
|
| Rate for Payer: Cigna Commercial |
$47.43
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$47.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$47.43
|
| Rate for Payer: Multiplan Commercial |
$55.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$50.40
|
| Rate for Payer: United Healthcare Commercial |
$56.33
|
|
|
GLUCOSE POST GLUCOSE DOSE
|
Facility
|
OP
|
$60.75
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
3008295001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna of VT Commercial |
$57.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$26.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$36.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$49.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.30
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna Commercial |
$48.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$48.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$48.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.34
|
| Rate for Payer: Multiplan Commercial |
$56.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.34
|
| Rate for Payer: United Healthcare Commercial |
$57.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.75
|
| Rate for Payer: United Healthcare VA CCN |
$27.34
|
|
|
GLUCOSE POST GLUCOSE DOSE
|
Facility
|
IP
|
$60.75
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
3008295001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.96 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna of VT Commercial |
$57.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.60
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna Commercial |
$48.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$48.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$48.60
|
| Rate for Payer: Multiplan Commercial |
$56.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.64
|
| Rate for Payer: United Healthcare Commercial |
$57.71
|
|
|
GLUCOSE TABLET 4 GM
|
Professional
|
Both
|
$0.03
|
|
| Hospital Charge Code |
2500000516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
GLUCOSE TOLERANCE TEST (GTT)
|
Facility
|
OP
|
$179.92
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
3008295101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna of VT Commercial |
$170.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$63.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$79.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$63.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$108.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$145.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.04
|
| Rate for Payer: Cash Price |
$89.96
|
| Rate for Payer: Cash Price |
$89.96
|
| Rate for Payer: Cigna Commercial |
$143.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.96
|
| Rate for Payer: Multiplan Commercial |
$167.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.96
|
| Rate for Payer: United Healthcare Commercial |
$170.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.87
|
| Rate for Payer: United Healthcare VA CCN |
$80.96
|
|
|
GLUCOSE TOLERANCE TEST (GTT)
|
Facility
|
IP
|
$179.92
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
3008295101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.16 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna of VT Commercial |
$170.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$133.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$133.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$152.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$151.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.94
|
| Rate for Payer: Cash Price |
$89.96
|
| Rate for Payer: Cigna Commercial |
$143.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$143.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$143.94
|
| Rate for Payer: Multiplan Commercial |
$167.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.93
|
| Rate for Payer: United Healthcare Commercial |
$170.92
|
|
|
GMK SPHERIKA FEM COMP S1+R CEM
|
Facility
|
OP
|
$2,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,151.54 |
| Max. Negotiated Rate |
$2,470.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,470.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,329.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,151.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,329.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,565.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,210.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,106.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,170.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,067.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$2,080.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,080.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,080.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,170.00
|
| Rate for Payer: Multiplan Commercial |
$2,418.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,210.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,170.00
|
| Rate for Payer: United Healthcare Commercial |
$2,470.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,170.00
|
| Rate for Payer: United Healthcare VA CCN |
$1,170.00
|
|
|
GMK SPHERIKA FEM COMP S1+R CEM
|
Facility
|
IP
|
$2,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780074651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,924.26 |
| Max. Negotiated Rate |
$2,470.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,470.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,924.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,924.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,210.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,184.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,080.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$2,080.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,080.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,080.00
|
| Rate for Payer: Multiplan Commercial |
$2,418.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,210.00
|
| Rate for Payer: United Healthcare Commercial |
$2,470.00
|
|
|
GMK SPHERIKA FEM COMP S2+L CEM
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,144.90 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,144.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,556.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,093.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,163.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,055.07
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,163.25
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,163.25
|
|
|
GMK SPHERIKA FEM COMP S2+L CEM
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,913.16 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,171.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,068.00
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
|
|
GMK SPHERIKA FEM COMP S3+L CEM
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,144.90 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,144.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,556.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,093.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,163.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,055.07
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,163.25
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,163.25
|
|
|
GMK SPHERIKA FEM COMP S3+L CEM
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072161
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,913.16 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,171.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,068.00
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
|
|
GMK SPHERIKA FEM COMP S5+L CEM
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,913.16 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,171.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,068.00
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
|
|
GMK SPHERIKA FEM COMP S5+L CEM
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,144.90 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,144.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,556.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,093.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,163.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,055.07
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,163.25
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,163.25
|
|
|
GMK SPH FEB COMP S5L CEMENTED
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,913.16 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,913.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,171.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,068.00
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
|
|
GMK SPH FEB COMP S5L CEMENTED
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,144.90 |
| Max. Negotiated Rate |
$2,455.75 |
| Rate for Payer: Aetna of VT Commercial |
$2,455.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,144.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,315.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,556.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,197.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,093.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,163.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,055.07
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,068.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,068.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,163.25
|
| Rate for Payer: Multiplan Commercial |
$2,404.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,197.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare Commercial |
$2,455.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,163.25
|
| Rate for Payer: United Healthcare VA CCN |
$1,163.25
|
|
