|
INJECT EPIDURAL PATCH
|
Facility
|
IP
|
$883.41
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
4506227301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$653.81 |
| Max. Negotiated Rate |
$839.24 |
| Rate for Payer: Aetna of VT Commercial |
$839.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$653.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$653.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$750.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$742.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$706.73
|
| Rate for Payer: Cash Price |
$441.70
|
| Rate for Payer: Cigna Commercial |
$706.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$706.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$706.73
|
| Rate for Payer: Multiplan Commercial |
$821.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$750.90
|
| Rate for Payer: United Healthcare Commercial |
$839.24
|
|
|
INJECT EPIDURAL PATCH
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9816227301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
INJECT EPIDURAL PATCH
|
Facility
|
IP
|
$701.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9816227302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$518.81 |
| Max. Negotiated Rate |
$665.95 |
| Rate for Payer: Aetna of VT Commercial |
$665.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$518.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$518.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$595.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$588.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$560.80
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cigna Commercial |
$560.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$560.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$560.80
|
| Rate for Payer: Multiplan Commercial |
$651.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$595.85
|
| Rate for Payer: United Healthcare Commercial |
$665.95
|
|
|
INJECT EPIDURAL PATCH
|
Professional
|
Both
|
$701.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9816227302
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$106.15 |
| Max. Negotiated Rate |
$658.94 |
| Rate for Payer: Aetna of VT Commercial |
$658.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$109.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$148.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$122.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$233.00
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cigna Commercial |
$147.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$651.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$150.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare Commercial |
$163.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare VA CCN |
$106.15
|
|
|
INJECT EPIDURAL PATCH
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9816227301
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$258.18 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$109.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$148.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$122.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$233.00
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$147.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$150.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare Commercial |
$163.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare VA CCN |
$106.15
|
|
|
INJECT EPIDURAL PATCH
|
Professional
|
Both
|
$701.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9826227301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$106.15 |
| Max. Negotiated Rate |
$658.94 |
| Rate for Payer: Aetna of VT Commercial |
$658.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$109.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$148.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$233.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$122.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$233.00
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cigna Commercial |
$147.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$258.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$258.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$158.50
|
| Rate for Payer: Multiplan Commercial |
$651.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$150.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare Commercial |
$163.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.15
|
| Rate for Payer: United Healthcare VA CCN |
$106.15
|
|
|
INJECT EPIDURAL PATCH
|
Facility
|
OP
|
$701.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
9826227301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$310.47 |
| Max. Negotiated Rate |
$665.95 |
| Rate for Payer: Aetna of VT Commercial |
$665.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$310.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$628.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$422.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$595.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$567.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$315.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$557.29
|
| Rate for Payer: Cash Price |
$350.50
|
| Rate for Payer: Cigna Commercial |
$560.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$560.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$560.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$315.45
|
| Rate for Payer: Multiplan Commercial |
$651.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$595.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$315.45
|
| Rate for Payer: United Healthcare Commercial |
$665.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$315.45
|
| Rate for Payer: United Healthcare VA CCN |
$315.45
|
|
|
INJECTION FOR BLADDER X-RAY
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
9725160001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$40.08 |
| Max. Negotiated Rate |
$489.48 |
| Rate for Payer: Aetna of VT Commercial |
$479.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$456.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$456.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$56.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$489.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$489.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$46.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$489.48
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$69.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$314.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$314.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$195.54
|
| Rate for Payer: Multiplan Commercial |
$474.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.08
|
| Rate for Payer: United Healthcare Commercial |
$61.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.08
|
| Rate for Payer: United Healthcare VA CCN |
$40.08
|
|
|
INJECTION FOR BLADDER X-RAY
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
9725160001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$225.88 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Aetna of VT Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$456.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$225.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$456.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$307.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$433.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$413.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$229.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$405.45
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$408.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$408.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$229.50
|
| Rate for Payer: Multiplan Commercial |
$474.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$433.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$229.50
|
| Rate for Payer: United Healthcare Commercial |
$484.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.50
|
| Rate for Payer: United Healthcare VA CCN |
$229.50
|
|
|
INJECTION FOR BLADDER X-RAY
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
9725160001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$377.45 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Aetna of VT Commercial |
$484.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$377.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$377.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$433.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$428.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$408.00
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$408.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$408.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$408.00
|
| Rate for Payer: Multiplan Commercial |
$474.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$433.50
|
| Rate for Payer: United Healthcare Commercial |
$484.50
|
|
|
INJECTION FOR BLADDER X-RAY
|
Facility
|
OP
|
$2,755.61
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3205160001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,220.46 |
| Max. Negotiated Rate |
$2,617.83 |
| Rate for Payer: Aetna of VT Commercial |
$2,617.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,468.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,220.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,468.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,658.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,342.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,232.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,240.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,190.71
|
| Rate for Payer: Cash Price |
$1,377.81
|
| Rate for Payer: Cigna Commercial |
$2,204.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,204.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,204.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,240.02
|
| Rate for Payer: Multiplan Commercial |
$2,562.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,342.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,240.02
|
| Rate for Payer: United Healthcare Commercial |
$2,617.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,240.02
|
| Rate for Payer: United Healthcare VA CCN |
$1,240.02
|
|
|
INJECTION FOR BLADDER X-RAY
|
Facility
|
IP
|
$2,755.61
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3205160001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,039.43 |
| Max. Negotiated Rate |
$2,617.83 |
| Rate for Payer: Aetna of VT Commercial |
$2,617.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,039.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,039.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,342.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,314.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,204.49
|
| Rate for Payer: Cash Price |
$1,377.81
|
| Rate for Payer: Cigna Commercial |
$2,204.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,204.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,204.49
|
| Rate for Payer: Multiplan Commercial |
$2,562.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,342.27
|
| Rate for Payer: United Healthcare Commercial |
$2,617.83
|
|
|
INJECTION FOR SHOULDER X-RAY
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 23350 26
|
| Hospital Charge Code |
9722335001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$77.06 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$77.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$104.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$138.33
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.30
|
| Rate for Payer: United Healthcare VA CCN |
$78.30
|
|
|
INJECTION FOR SHOULDER X-RAY
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 23350 26
|
| Hospital Charge Code |
9722335001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna of VT Commercial |
$165.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$147.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$146.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$139.20
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$139.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$139.20
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$147.90
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
|
|
INJECTION FOR SHOULDER X-RAY
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 23350 26
|
| Hospital Charge Code |
9722335001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$69.60 |
| Max. Negotiated Rate |
$399.01 |
| Rate for Payer: Aetna of VT Commercial |
$163.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$399.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$399.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$399.01
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$87.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$150.30
|
| Rate for Payer: Multiplan Commercial |
$161.82
|
| Rate for Payer: United Healthcare Commercial |
$147.90
|
| Rate for Payer: United Healthcare VA CCN |
$69.60
|
|
|
INJECTION FOR SHOULDER X-RAY
|
Facility
|
OP
|
$499.16
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3202335001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$221.08 |
| Max. Negotiated Rate |
$474.20 |
| Rate for Payer: Aetna of VT Commercial |
$474.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$221.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$300.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$424.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$404.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$224.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$396.83
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cigna Commercial |
$399.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$399.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$399.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$224.62
|
| Rate for Payer: Multiplan Commercial |
$464.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$424.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$224.62
|
| Rate for Payer: United Healthcare Commercial |
$474.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$224.62
|
| Rate for Payer: United Healthcare VA CCN |
$224.62
|
|
|
INJECTION FOR SHOULDER X-RAY
|
Facility
|
IP
|
$499.16
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3202335001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$369.43 |
| Max. Negotiated Rate |
$474.20 |
| Rate for Payer: Aetna of VT Commercial |
$474.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$369.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$369.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$424.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$419.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$399.33
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cigna Commercial |
$399.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$399.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$399.33
|
| Rate for Payer: Multiplan Commercial |
$464.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$424.29
|
| Rate for Payer: United Healthcare Commercial |
$474.20
|
|
|
INJECTION, FULPHILA .5 MG
|
Professional
|
Both
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.13 |
| Max. Negotiated Rate |
$5,715.20 |
| Rate for Payer: Aetna of VT Commercial |
$5,715.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$114.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$125.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$125.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$99.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare Commercial |
$152.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare VA CCN |
$99.13
|
|
|
INJECTION, FULPHILA .5 MG
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$310.48 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,692.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,660.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,924.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,736.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,833.60
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,736.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare VA CCN |
$2,736.00
|
|
|
INJECTION, FULPHILA .5 MG
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,499.81 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,107.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,864.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
|
|
INJECTION,FULPHILA .5MG*340B*
|
Professional
|
Both
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.13 |
| Max. Negotiated Rate |
$5,715.20 |
| Rate for Payer: Aetna of VT Commercial |
$5,715.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$114.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$125.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$125.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$99.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare Commercial |
$152.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare VA CCN |
$99.13
|
|
|
INJECTION,FULPHILA .5MG*340B*
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$310.48 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,692.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,660.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,924.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,736.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,833.60
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,736.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare VA CCN |
$2,736.00
|
|
|
INJECTION,FULPHILA .5MG*340B*
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
636Q510802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,499.81 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,107.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,864.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
|
|
INJECTION,FULPHILA .5MG*340B*
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108 TB
|
| Hospital Charge Code |
636Q510802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$310.48 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,692.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$310.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,660.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,924.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,736.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,833.60
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,736.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,736.00
|
| Rate for Payer: United Healthcare VA CCN |
$2,736.00
|
|
|
INJECTION,FULPHILA .5MG*340B*
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
HCPCS Q5108 TB
|
| Hospital Charge Code |
636Q510802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,499.81 |
| Max. Negotiated Rate |
$5,776.00 |
| Rate for Payer: Aetna of VT Commercial |
$5,776.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,499.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,107.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,864.00
|
| Rate for Payer: Cash Price |
$3,040.00
|
| Rate for Payer: Cigna Commercial |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,864.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,864.00
|
| Rate for Payer: Multiplan Commercial |
$5,654.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,168.00
|
| Rate for Payer: United Healthcare Commercial |
$5,776.00
|
|
