|
GMK SPH FEM COMP S4R CEMENTED
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071951
|
|
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 FEM COMP S4R CEMENTED
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780071951
|
|
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 FEM COMP S5R CEMENTED
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075191
|
|
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 FEM COMP S5R CEMENTED
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075191
|
|
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 FEM COMP S6+L CEMENTED
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072141
|
|
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 FEM COMP S6+L CEMENTED
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072141
|
|
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 FEM COMP S6L CEMENTED
|
Facility
|
OP
|
$8,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,764.65 |
| Max. Negotiated Rate |
$8,075.00 |
| Rate for Payer: Aetna of VT Commercial |
$8,075.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7,615.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,764.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7,615.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5,117.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,225.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,885.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,825.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,757.50
|
| Rate for Payer: Cash Price |
$4,250.00
|
| Rate for Payer: Cigna Commercial |
$6,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,800.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,825.00
|
| Rate for Payer: Multiplan Commercial |
$7,905.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,225.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,825.00
|
| Rate for Payer: United Healthcare Commercial |
$8,075.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,825.00
|
| Rate for Payer: United Healthcare VA CCN |
$3,825.00
|
|
|
GMK SPH FEM COMP S6L CEMENTED
|
Facility
|
IP
|
$8,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,290.85 |
| Max. Negotiated Rate |
$8,075.00 |
| Rate for Payer: Aetna of VT Commercial |
$8,075.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,290.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,290.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7,225.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7,140.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6,800.00
|
| Rate for Payer: Cash Price |
$4,250.00
|
| Rate for Payer: Cigna Commercial |
$6,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6,800.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6,800.00
|
| Rate for Payer: Multiplan Commercial |
$7,905.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,225.00
|
| Rate for Payer: United Healthcare Commercial |
$8,075.00
|
|
|
GMK SPH FEM COMP S6R CEMENTED
|
Facility
|
IP
|
$2,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,905.76 |
| Max. Negotiated Rate |
$2,446.25 |
| Rate for Payer: Aetna of VT Commercial |
$2,446.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,905.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,905.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,188.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,163.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,060.00
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,060.00
|
| Rate for Payer: Multiplan Commercial |
$2,394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,188.75
|
| Rate for Payer: United Healthcare Commercial |
$2,446.25
|
|
|
GMK SPH FEM COMP S6R CEMENTED
|
Facility
|
OP
|
$2,575.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780073761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.47 |
| Max. Negotiated Rate |
$2,446.25 |
| Rate for Payer: Aetna of VT Commercial |
$2,446.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,140.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,306.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,550.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,188.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,085.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,158.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,047.12
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,060.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,060.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,158.75
|
| Rate for Payer: Multiplan Commercial |
$2,394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,188.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,158.75
|
| Rate for Payer: United Healthcare Commercial |
$2,446.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,158.75
|
| Rate for Payer: United Healthcare VA CCN |
$1,158.75
|
|
|
GMK SPH TIB INS ECROSS 2L 10MM
|
Facility
|
OP
|
$1,241.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.64 |
| Max. Negotiated Rate |
$1,178.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$549.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,111.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$747.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,005.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$558.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$986.60
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$558.45
|
| Rate for Payer: Multiplan Commercial |
$1,154.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$558.45
|
| Rate for Payer: United Healthcare Commercial |
$1,178.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$558.45
|
| Rate for Payer: United Healthcare VA CCN |
$558.45
|
|
|
GMK SPH TIB INS ECROSS 2L 10MM
|
Facility
|
IP
|
$1,241.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$918.46 |
| Max. Negotiated Rate |
$1,178.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$918.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$918.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,042.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$992.80
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.80
|
| Rate for Payer: Multiplan Commercial |
$1,154.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.85
|
| Rate for Payer: United Healthcare Commercial |
$1,178.95
|
|
|
GMK SPH TIB INS ECROSS 3L 11MM
|
Facility
|
OP
|
$1,248.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$552.74 |
| Max. Negotiated Rate |
$1,185.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,185.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,118.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$552.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,118.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$751.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,060.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,010.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$561.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$992.16
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cigna Commercial |
$998.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$998.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$998.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$561.60
|
| Rate for Payer: Multiplan Commercial |
$1,160.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,060.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$561.60
|
| Rate for Payer: United Healthcare Commercial |
$1,185.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$561.60
|
| Rate for Payer: United Healthcare VA CCN |
$561.60
|
|
|
GMK SPH TIB INS ECROSS 3L 11MM
|
Facility
|
IP
|
$1,248.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$923.64 |
| Max. Negotiated Rate |
$1,185.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,185.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$923.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$923.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,060.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,048.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$998.40
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cigna Commercial |
$998.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$998.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$998.40
|
| Rate for Payer: Multiplan Commercial |
$1,160.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,060.80
|
| Rate for Payer: United Healthcare Commercial |
$1,185.60
|
|
|
GMK SPH TIB INS ECROSS 6L 10MM
|
Facility
|
OP
|
$1,240.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.55 |
| Max. Negotiated Rate |
$1,178.76 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,111.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$549.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,111.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$746.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,005.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$558.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$986.44
|
| Rate for Payer: Cash Price |
$620.40
|
| Rate for Payer: Cigna Commercial |
$992.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$558.36
|
| Rate for Payer: Multiplan Commercial |
$1,153.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.68
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$558.36
|
| Rate for Payer: United Healthcare Commercial |
$1,178.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$558.36
|
| Rate for Payer: United Healthcare VA CCN |
$558.36
|
|
|
GMK SPH TIB INS ECROSS 6L 10MM
|
Facility
|
IP
|
$1,240.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780072131
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$918.32 |
| Max. Negotiated Rate |
$1,178.76 |
| Rate for Payer: Aetna of VT Commercial |
$1,178.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$918.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$918.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,054.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,042.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$992.64
|
| Rate for Payer: Cash Price |
$620.40
|
| Rate for Payer: Cigna Commercial |
$992.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$992.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$992.64
|
| Rate for Payer: Multiplan Commercial |
$1,153.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,054.68
|
| Rate for Payer: United Healthcare Commercial |
$1,178.76
|
|
|
GMK-SPH TIB INS ECROSS FLEX 5L
|
Facility
|
OP
|
$4,080.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780056511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,807.03 |
| Max. Negotiated Rate |
$3,876.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,876.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,655.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,807.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,655.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,456.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,468.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,304.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,836.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,243.60
|
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$3,264.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,264.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,264.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,836.00
|
| Rate for Payer: Multiplan Commercial |
$3,794.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,468.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,836.00
|
| Rate for Payer: United Healthcare Commercial |
$3,876.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,836.00
|
| Rate for Payer: United Healthcare VA CCN |
$1,836.00
|
|
|
GMK-SPH TIB INS ECROSS FLEX 5L
|
Facility
|
IP
|
$4,080.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780056511
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,019.61 |
| Max. Negotiated Rate |
$3,876.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,876.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,019.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,019.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,468.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,427.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,264.00
|
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Cigna Commercial |
$3,264.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,264.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,264.00
|
| Rate for Payer: Multiplan Commercial |
$3,794.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,468.00
|
| Rate for Payer: United Healthcare Commercial |
$3,876.00
|
|
|
GROUP CAREGIVER TRAINING
|
Facility
|
OP
|
$31.95
|
|
|
Service Code
|
CPT 97552
|
| Hospital Charge Code |
9429755201
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$14.15 |
| Max. Negotiated Rate |
$30.35 |
| Rate for Payer: Aetna of VT Commercial |
$30.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$25.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.40
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna Commercial |
$25.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$25.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$25.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.38
|
| Rate for Payer: Multiplan Commercial |
$29.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.38
|
| Rate for Payer: United Healthcare Commercial |
$30.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.38
|
| Rate for Payer: United Healthcare VA CCN |
$14.38
|
|
|
GROUP CAREGIVER TRAINING
|
Facility
|
IP
|
$31.95
|
|
|
Service Code
|
CPT 97552
|
| Hospital Charge Code |
9429755201
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$23.65 |
| Max. Negotiated Rate |
$30.35 |
| Rate for Payer: Aetna of VT Commercial |
$30.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.56
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna Commercial |
$25.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$25.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$25.56
|
| Rate for Payer: Multiplan Commercial |
$29.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.16
|
| Rate for Payer: United Healthcare Commercial |
$30.35
|
|
|
GUAIFENESIN W CODEINE LIQ 10ML
|
Facility
|
IP
|
$0.01
|
|
| Hospital Charge Code |
2500000556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
GUAIFENESIN W CODEINE LIQ 10ML
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 121077504
|
| Hospital Charge Code |
2500000556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
GUAIFENESIN W CODEINE LIQ 10ML
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
2500000556
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
GUAIFENESIN W CODEINE LIQ 10ML
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 121077504
|
| Hospital Charge Code |
2500000556
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
HALOPERIDOL INJECTION
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
637J163001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.80
|
| Rate for Payer: United Healthcare VA CCN |
$0.80
|
|
