|
HEMOGLOBIN ELECTROPHORESIS
|
Facility
|
IP
|
$348.20
|
|
|
Service Code
|
CPT 83020
|
| Hospital Charge Code |
3008302001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$257.70 |
| Max. Negotiated Rate |
$330.79 |
| Rate for Payer: Aetna of VT Commercial |
$330.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$257.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$257.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$295.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$292.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$278.56
|
| Rate for Payer: Cash Price |
$174.10
|
| Rate for Payer: Cigna Commercial |
$278.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$278.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$278.56
|
| Rate for Payer: Multiplan Commercial |
$323.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$295.97
|
| Rate for Payer: United Healthcare Commercial |
$330.79
|
|
|
HEMOGLOBIN FETAL
|
Facility
|
OP
|
$118.29
|
|
|
Service Code
|
CPT 85460
|
| Hospital Charge Code |
3008546001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.73 |
| 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 |
$38.09
|
| 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 |
$38.09
|
| 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: 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 |
$100.55
|
| 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 |
$7.73
|
| Rate for Payer: United Healthcare VA CCN |
$53.23
|
|
|
HEMOGLOBIN FETAL
|
Facility
|
IP
|
$118.29
|
|
|
Service Code
|
CPT 85460
|
| Hospital Charge Code |
3008546001
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
HEMOGLOBIN FETAL
|
Professional
|
Both
|
$118.29
|
|
|
Service Code
|
CPT 85460
|
| Hospital Charge Code |
3008546001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$111.19 |
| Rate for Payer: Aetna of VT Commercial |
$111.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$38.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$38.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$10.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.22
|
| Rate for Payer: Cash Price |
$59.15
|
| Rate for Payer: Cash Price |
$59.15
|
| Rate for Payer: Cigna Commercial |
$9.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.62
|
| Rate for Payer: Multiplan Commercial |
$110.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.73
|
| Rate for Payer: United Healthcare Commercial |
$11.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.73
|
| Rate for Payer: United Healthcare VA CCN |
$7.73
|
|
|
HEMOGLOBIN FETAL
|
Facility
|
IP
|
$235.75
|
|
|
Service Code
|
CPT 85461
|
| Hospital Charge Code |
3008546101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$174.48 |
| Max. Negotiated Rate |
$223.96 |
| Rate for Payer: Aetna of VT Commercial |
$223.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$174.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$174.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$200.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$198.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.60
|
| Rate for Payer: Cash Price |
$117.88
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$219.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.39
|
| Rate for Payer: United Healthcare Commercial |
$223.96
|
|
|
HEMOGLOBIN FETAL
|
Professional
|
Both
|
$235.75
|
|
|
Service Code
|
CPT 85461
|
| Hospital Charge Code |
3008546101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$221.60 |
| Rate for Payer: Aetna of VT Commercial |
$221.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$46.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$9.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$46.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$13.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$10.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$15.73
|
| Rate for Payer: Cash Price |
$117.88
|
| Rate for Payer: Cash Price |
$117.88
|
| Rate for Payer: Cigna Commercial |
$11.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.23
|
| Rate for Payer: Multiplan Commercial |
$219.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.36
|
| Rate for Payer: United Healthcare VA CCN |
$9.36
|
|
|
HEMOGLOBIN FETAL
|
Facility
|
OP
|
$235.75
|
|
|
Service Code
|
CPT 85461
|
| Hospital Charge Code |
3008546101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$223.96 |
| Rate for Payer: Aetna of VT Commercial |
$223.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$46.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$104.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$46.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$141.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$200.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$190.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$106.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$187.42
|
| Rate for Payer: Cash Price |
$117.88
|
| Rate for Payer: Cash Price |
$117.88
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$106.09
|
| Rate for Payer: Multiplan Commercial |
$219.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$106.09
|
| Rate for Payer: United Healthcare Commercial |
$223.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.36
|
| Rate for Payer: United Healthcare VA CCN |
$106.09
|
|
|
HEMOGLOBIN GLYCOSYLATED A1C
|
Facility
|
IP
|
$104.43
|
|
|
Service Code
|
CPT 83036
|
| Hospital Charge Code |
3008303601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.29 |
| Max. Negotiated Rate |
$99.21 |
| Rate for Payer: Aetna of VT Commercial |
$99.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$83.54
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cigna Commercial |
$83.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$83.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$83.54
|
| Rate for Payer: Multiplan Commercial |
$97.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.77
|
| Rate for Payer: United Healthcare Commercial |
$99.21
|
|
|
HEMOGLOBIN GLYCOSYLATED A1C
|
Facility
|
OP
|
$104.43
|
|
|
Service Code
|
CPT 83036
|
| Hospital Charge Code |
3008303601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$99.21 |
| Rate for Payer: Aetna of VT Commercial |
$99.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$46.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$62.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$84.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$46.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$83.02
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cigna Commercial |
$83.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$83.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$83.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$46.99
|
| Rate for Payer: Multiplan Commercial |
$97.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$88.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$46.99
|
| Rate for Payer: United Healthcare Commercial |
$99.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.71
|
| Rate for Payer: United Healthcare VA CCN |
$46.99
|
|
|
HEMOGLOBIN GLYCOSYLATED A1C
|
Professional
|
Both
|
$104.43
|
|
|
Service Code
|
CPT 83036
|
| Hospital Charge Code |
3008303601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.57 |
| Max. Negotiated Rate |
$98.16 |
| Rate for Payer: Aetna of VT Commercial |
$98.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$47.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$47.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$13.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$11.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.59
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$97.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$9.71
|
| Rate for Payer: United Healthcare Commercial |
$14.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.71
|
| Rate for Payer: United Healthcare VA CCN |
$9.71
|
|
|
HEMOSTAT GELFOAM DENTAL SZ 4
|
Facility
|
IP
|
$94.00
|
|
| Hospital Charge Code |
2720024031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.57 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Aetna of VT Commercial |
$89.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$69.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$69.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$79.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$78.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$75.20
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cigna Commercial |
$75.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$75.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$75.20
|
| Rate for Payer: Multiplan Commercial |
$87.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$79.90
|
| Rate for Payer: United Healthcare Commercial |
$89.30
|
|
|
HEMOSTAT GELFOAM DENTAL SZ 4
|
Facility
|
OP
|
$94.00
|
|
| Hospital Charge Code |
2720024031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.63 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Aetna of VT Commercial |
$89.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$56.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$79.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$74.73
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cigna Commercial |
$75.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$75.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$75.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$42.30
|
| Rate for Payer: Multiplan Commercial |
$87.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$79.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$42.30
|
| Rate for Payer: United Healthcare Commercial |
$89.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.30
|
| Rate for Payer: United Healthcare VA CCN |
$42.30
|
|
|
HEPA 720 ELU 2VLS=1 ADLT DOSE
|
Professional
|
Both
|
$30.16
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
6369063303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.64 |
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Aetna of VT Commercial |
$28.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$44.67
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$41.33
|
| Rate for Payer: Multiplan Commercial |
$28.05
|
| Rate for Payer: United Healthcare Commercial |
$25.64
|
| Rate for Payer: United Healthcare VA CCN |
$56.00
|
|
|
HEPA 720 ELU 2VLS=1 ADLT DOSE
|
Facility
|
IP
|
$30.16
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
6369063303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$28.65 |
| Rate for Payer: Aetna of VT Commercial |
$28.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$22.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$22.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$25.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$24.13
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna Commercial |
$24.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$24.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$24.13
|
| Rate for Payer: Multiplan Commercial |
$28.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.64
|
| Rate for Payer: United Healthcare Commercial |
$28.65
|
|
|
HEPA 720 ELU 2VLS=1 ADLT DOSE
|
Facility
|
OP
|
$30.16
|
|
|
Service Code
|
CPT 90633
|
| Hospital Charge Code |
6369063303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Aetna of VT Commercial |
$28.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.98
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna Commercial |
$24.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$24.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$24.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.57
|
| Rate for Payer: Multiplan Commercial |
$28.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.64
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.57
|
| Rate for Payer: United Healthcare Commercial |
$28.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.57
|
| Rate for Payer: United Healthcare VA CCN |
$13.57
|
|
|
HEP A/HEP B VACC ADULT IM
|
Facility
|
OP
|
$425.04
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
6369063601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.25 |
| Max. Negotiated Rate |
$403.79 |
| Rate for Payer: Aetna of VT Commercial |
$403.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$188.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$255.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$361.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$344.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$191.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$337.91
|
| Rate for Payer: Cash Price |
$212.52
|
| Rate for Payer: Cash Price |
$212.52
|
| Rate for Payer: Cigna Commercial |
$340.03
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$340.03
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$340.03
|
| Rate for Payer: Martins Point Health Care Commercial |
$191.27
|
| Rate for Payer: Multiplan Commercial |
$395.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$361.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$191.27
|
| Rate for Payer: United Healthcare Commercial |
$403.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$191.27
|
| Rate for Payer: United Healthcare VA CCN |
$191.27
|
|
|
HEP A/HEP B VACC ADULT IM
|
Facility
|
IP
|
$425.04
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
6369063601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$314.57 |
| Max. Negotiated Rate |
$403.79 |
| Rate for Payer: Aetna of VT Commercial |
$403.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$314.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$314.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$361.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$340.03
|
| Rate for Payer: Cash Price |
$212.52
|
| Rate for Payer: Cigna Commercial |
$340.03
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$340.03
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$340.03
|
| Rate for Payer: Multiplan Commercial |
$395.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$361.28
|
| Rate for Payer: United Healthcare Commercial |
$403.79
|
|
|
HEP A/HEP B VACC ADULT IM
|
Professional
|
Both
|
$425.04
|
|
|
Service Code
|
CPT 90636
|
| Hospital Charge Code |
6369063601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.28 |
| Max. Negotiated Rate |
$399.54 |
| Rate for Payer: Aetna of VT Commercial |
$399.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$364.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$129.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$129.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$129.28
|
| Rate for Payer: Cash Price |
$212.52
|
| Rate for Payer: Cash Price |
$212.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$178.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$178.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$140.38
|
| Rate for Payer: Multiplan Commercial |
$395.29
|
| Rate for Payer: United Healthcare Commercial |
$361.28
|
| Rate for Payer: United Healthcare VA CCN |
$130.00
|
|
|
HEPARIN 5,000 UNIT/ML VIAL
|
Professional
|
Both
|
$1.28
|
|
|
Service Code
|
NDC 6332326206
|
| Hospital Charge Code |
2500000130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of VT Commercial |
$1.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.15
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare VA CCN |
$0.51
|
|
|
HEPARIN 5,000 UNIT/ML VIAL
|
Professional
|
Both
|
$1.28
|
|
| Hospital Charge Code |
2500000130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of VT Commercial |
$1.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.15
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare VA CCN |
$0.51
|
|
|
HEPARIN 500 UNIT/5 ML SYRINGE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
636J164201
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
HEPARIN 500 UNIT/5 ML SYRINGE
|
Professional
|
Both
|
$3.64
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
636J164201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna of VT Commercial |
$3.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.02
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.02
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.02
|
| Rate for Payer: United Healthcare VA CCN |
$0.02
|
|
|
HEPARIN 500 UNIT/5 ML SYRINGE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J1642
|
| Hospital Charge Code |
636J164201
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$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
|
|
|
HEPARIN ASSAY
|
Facility
|
IP
|
$139.59
|
|
|
Service Code
|
CPT 85520
|
| Hospital Charge Code |
3008552001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.31 |
| Max. Negotiated Rate |
$132.61 |
| Rate for Payer: Aetna of VT Commercial |
$132.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$103.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$103.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$118.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$117.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$111.67
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cigna Commercial |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.67
|
| Rate for Payer: Multiplan Commercial |
$129.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$118.65
|
| Rate for Payer: United Healthcare Commercial |
$132.61
|
|
|
HEPARIN ASSAY
|
Professional
|
Both
|
$139.59
|
|
|
Service Code
|
CPT 85520
|
| Hospital Charge Code |
3008552001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$131.21 |
| Rate for Payer: Aetna of VT Commercial |
$131.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.37
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.91
|
| Rate for Payer: Multiplan Commercial |
$129.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$20.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.09
|
| Rate for Payer: United Healthcare VA CCN |
$13.09
|
|
