|
INJECT TRIGGER POINTS 3/>
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9822055301
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$153.20 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna of VT Commercial |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$175.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$173.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.60
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$165.60
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.95
|
| Rate for Payer: United Healthcare Commercial |
$196.65
|
|
|
INJECT TRIGGER POINTS 3/>
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$38.77 |
| Max. Negotiated Rate |
$194.58 |
| Rate for Payer: Aetna of VT Commercial |
$194.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.07
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$74.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$93.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$93.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$57.08
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare Commercial |
$59.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare VA CCN |
$38.77
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$248.47 |
| Max. Negotiated Rate |
$532.95 |
| Rate for Payer: Aetna of VT Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$248.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$337.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$476.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$454.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$252.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$446.00
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$448.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.45
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$476.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$252.45
|
| Rate for Payer: United Healthcare Commercial |
$532.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$252.45
|
| Rate for Payer: United Healthcare VA CCN |
$252.45
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$91.68 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna of VT Commercial |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$91.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$124.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$175.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$167.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$93.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$164.56
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$165.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.15
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$196.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$93.15
|
| Rate for Payer: United Healthcare VA CCN |
$93.15
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055302
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$153.20 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna of VT Commercial |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$175.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$173.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.60
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$165.60
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.95
|
| Rate for Payer: United Healthcare Commercial |
$196.65
|
|
|
INJECT TRIGGER POINTS 3/>
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$38.77 |
| Max. Negotiated Rate |
$527.34 |
| Rate for Payer: Aetna of VT Commercial |
$527.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$502.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.07
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$74.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$93.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$93.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$57.08
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare Commercial |
$59.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare VA CCN |
$38.77
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
5102055301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$156.79 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Aetna of VT Commercial |
$336.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$317.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$156.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$317.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$213.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$300.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$286.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$159.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$281.43
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$283.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$283.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$283.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$159.30
|
| Rate for Payer: Multiplan Commercial |
$329.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$300.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$159.30
|
| Rate for Payer: United Healthcare Commercial |
$336.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$159.30
|
| Rate for Payer: United Healthcare VA CCN |
$159.30
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
9602055301
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$415.20 |
| Max. Negotiated Rate |
$532.95 |
| Rate for Payer: Aetna of VT Commercial |
$532.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$415.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$415.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$476.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$471.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$448.80
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$448.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$448.80
|
| Rate for Payer: Multiplan Commercial |
$521.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$476.85
|
| Rate for Payer: United Healthcare Commercial |
$532.95
|
|
|
INJECT TRIGGER POINTS 3/>
|
Professional
|
Both
|
$354.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
5102055301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.77 |
| Max. Negotiated Rate |
$332.76 |
| Rate for Payer: Aetna of VT Commercial |
$332.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$317.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$317.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.07
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$74.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$93.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$93.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$57.08
|
| Rate for Payer: Multiplan Commercial |
$329.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare Commercial |
$59.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare VA CCN |
$38.77
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
CPT 20553
|
| Hospital Charge Code |
5102055301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$262.00 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Aetna of VT Commercial |
$336.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$262.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$262.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$300.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$297.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$283.20
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$283.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$283.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$283.20
|
| Rate for Payer: Multiplan Commercial |
$329.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$300.90
|
| Rate for Payer: United Healthcare Commercial |
$336.30
|
|
|
INJ., FREMANEZUMAB-VFRM 1 MG
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS J3031
|
| Hospital Charge Code |
637J303101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.24
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare VA CCN |
$2.00
|
|
|
INJ., FREMANEZUMAB-VFRM 1 MG
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3031
|
| Hospital Charge Code |
637J303101
|
|
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
|
|
|
INJ., FREMANEZUMAB-VFRM 1 MG
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3031
|
| Hospital Charge Code |
637J303101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.24
|
| 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 |
$9.24
|
| 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
|
|
|
INJ GLUCAGON HCL, FRESENIUS
|
Facility
|
OP
|
$629.09
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
636J161101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$278.62 |
| Max. Negotiated Rate |
$597.64 |
| Rate for Payer: Aetna of VT Commercial |
$597.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$413.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$278.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$413.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$378.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$534.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$509.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$283.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$500.13
|
| Rate for Payer: Cash Price |
$314.54
|
| Rate for Payer: Cash Price |
$314.54
|
| Rate for Payer: Cigna Commercial |
$503.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$503.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$503.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$283.09
|
| Rate for Payer: Multiplan Commercial |
$585.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$534.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$283.09
|
| Rate for Payer: United Healthcare Commercial |
$597.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.09
|
| Rate for Payer: United Healthcare VA CCN |
$283.09
|
|
|
INJ GLUCAGON HCL, FRESENIUS
|
Facility
|
IP
|
$629.09
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
636J161101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.59 |
| Max. Negotiated Rate |
$597.64 |
| Rate for Payer: Aetna of VT Commercial |
$597.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$465.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$465.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$534.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$528.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$503.27
|
| Rate for Payer: Cash Price |
$314.54
|
| Rate for Payer: Cigna Commercial |
$503.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$503.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$503.27
|
| Rate for Payer: Multiplan Commercial |
$585.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$534.73
|
| Rate for Payer: United Healthcare Commercial |
$597.64
|
|
|
INJ, INVEGA SUSTENNA, 1 MG
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
636J242601
|
|
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
|
|
|
INJ, INVEGA SUSTENNA, 1 MG
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
636J242601
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$40.54 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.54
|
| 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 |
$40.54
|
| 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
|
|
|
INJ LEVOTHTROXINE NOS 100MCG
|
Facility
|
IP
|
$38.88
|
|
|
Service Code
|
NDC 6332364907
|
| Hospital Charge Code |
636J065001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$36.94 |
| Rate for Payer: Aetna of VT Commercial |
$36.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$33.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$31.10
|
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Cigna Commercial |
$31.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.10
|
| Rate for Payer: Multiplan Commercial |
$36.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.05
|
| Rate for Payer: United Healthcare Commercial |
$36.94
|
|
|
INJ LEVOTHTROXINE NOS 100MCG
|
Facility
|
OP
|
$38.88
|
|
|
Service Code
|
NDC 6332364907
|
| Hospital Charge Code |
636J065001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.22 |
| Max. Negotiated Rate |
$36.94 |
| Rate for Payer: Aetna of VT Commercial |
$36.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$34.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$33.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$31.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.91
|
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Cigna Commercial |
$31.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$31.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$31.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.50
|
| Rate for Payer: Multiplan Commercial |
$36.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.50
|
| Rate for Payer: United Healthcare Commercial |
$36.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.50
|
| Rate for Payer: United Healthcare VA CCN |
$17.50
|
|
|
INJ, METHYLPRED 1000 MG VIAL
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.69
|
|
|
INJ, METHYLPRED 1000 MG VIAL
|
Professional
|
Both
|
$42.16
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$39.63 |
| Rate for Payer: Aetna of VT Commercial |
$39.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.24
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$39.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Healthcare VA CCN |
$0.21
|
|
|
INJ, METHYLPRED 125 MG VIAL
|
Facility
|
OP
|
$7.67
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna of VT Commercial |
$7.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.10
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.52
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.45
|
| Rate for Payer: United Healthcare Commercial |
$7.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.45
|
| Rate for Payer: United Healthcare VA CCN |
$3.45
|
|
|
INJ, METHYLPRED 125 MG VIAL
|
Professional
|
Both
|
$7.67
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Aetna of VT Commercial |
$7.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.24
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.21
|
| Rate for Payer: United Healthcare VA CCN |
$0.21
|
|
|
INJ, METHYLPRED 125 MG VIAL
|
Facility
|
IP
|
$7.67
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna of VT Commercial |
$7.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.14
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna Commercial |
$6.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.14
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.52
|
| Rate for Payer: United Healthcare Commercial |
$7.29
|
|
|
INJ, METHYLPRED SOD SUCC 5MG
|
Facility
|
OP
|
$42.33
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
636J291901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$40.21 |
| Rate for Payer: Aetna of VT Commercial |
$40.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$35.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.65
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cigna Commercial |
$33.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$33.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$33.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$19.05
|
| Rate for Payer: Multiplan Commercial |
$39.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$19.05
|
| Rate for Payer: United Healthcare Commercial |
$40.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.05
|
| Rate for Payer: United Healthcare VA CCN |
$19.05
|
|
