|
ISLET CELL ANTIBODY
|
Facility
|
IP
|
$297.98
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
3008634101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$220.53 |
| Max. Negotiated Rate |
$283.08 |
| Rate for Payer: Aetna of VT Commercial |
$283.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$220.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$220.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$253.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$250.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$238.38
|
| Rate for Payer: Cash Price |
$148.99
|
| Rate for Payer: Cigna Commercial |
$238.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$238.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$238.38
|
| Rate for Payer: Multiplan Commercial |
$277.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$253.28
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
|
|
ISLET CELL ANTIBODY
|
Facility
|
OP
|
$297.98
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
3008634101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.57 |
| Max. Negotiated Rate |
$283.08 |
| Rate for Payer: Aetna of VT Commercial |
$283.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$131.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$179.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$253.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$241.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$134.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$236.89
|
| Rate for Payer: Cash Price |
$148.99
|
| Rate for Payer: Cash Price |
$148.99
|
| Rate for Payer: Cigna Commercial |
$238.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$238.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$238.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$134.09
|
| Rate for Payer: Multiplan Commercial |
$277.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$253.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$134.09
|
| Rate for Payer: United Healthcare Commercial |
$283.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.57
|
| Rate for Payer: United Healthcare VA CCN |
$134.09
|
|
|
ISLET CELL ANTIBODY
|
Professional
|
Both
|
$297.98
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
3008634101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.24 |
| Max. Negotiated Rate |
$280.10 |
| Rate for Payer: Aetna of VT Commercial |
$280.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$24.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$40.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$40.30
|
| Rate for Payer: Cash Price |
$148.99
|
| Rate for Payer: Cash Price |
$148.99
|
| Rate for Payer: Cigna Commercial |
$28.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$23.24
|
| Rate for Payer: Multiplan Commercial |
$277.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$23.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$23.57
|
| Rate for Payer: United Healthcare Commercial |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.57
|
| Rate for Payer: United Healthcare VA CCN |
$23.57
|
|
|
ISOVUE 370 100 ML
|
Facility
|
OP
|
$63.14
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
636Q996701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$59.98 |
| Rate for Payer: Aetna of VT Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$38.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$53.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$28.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.20
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cigna Commercial |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$50.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$28.41
|
| Rate for Payer: Multiplan Commercial |
$58.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.67
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$28.41
|
| Rate for Payer: United Healthcare Commercial |
$59.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.41
|
| Rate for Payer: United Healthcare VA CCN |
$28.41
|
|
|
ISOVUE 370 100 ML
|
Facility
|
IP
|
$63.14
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
636Q996701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.73 |
| Max. Negotiated Rate |
$59.98 |
| Rate for Payer: Aetna of VT Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$46.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$46.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$53.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$53.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.51
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cigna Commercial |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$50.51
|
| Rate for Payer: Multiplan Commercial |
$58.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.67
|
| Rate for Payer: United Healthcare Commercial |
$59.98
|
|
|
ISOVUE-M 200 10VL x 10ML
|
Facility
|
IP
|
$63.14
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550045681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.73 |
| Max. Negotiated Rate |
$59.98 |
| Rate for Payer: Aetna of VT Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$46.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$46.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$53.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$53.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.51
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cigna Commercial |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$50.51
|
| Rate for Payer: Multiplan Commercial |
$58.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.67
|
| Rate for Payer: United Healthcare Commercial |
$59.98
|
|
|
ISOVUE-M 200 10VL x 10ML
|
Facility
|
OP
|
$63.14
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550045681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$59.98 |
| Rate for Payer: Aetna of VT Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$38.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$53.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$28.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.20
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cash Price |
$31.57
|
| Rate for Payer: Cigna Commercial |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$50.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$50.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$28.41
|
| Rate for Payer: Multiplan Commercial |
$58.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.67
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$28.41
|
| Rate for Payer: United Healthcare Commercial |
$59.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.41
|
| Rate for Payer: United Healthcare VA CCN |
$28.41
|
|
|
ITRACONAZOLE 100MG CAPSULE
|
Facility
|
IP
|
$8.78
|
|
| Hospital Charge Code |
2500000587
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of VT Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.02
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna Commercial |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$8.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.46
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
|
|
ITRACONAZOLE 100MG CAPSULE
|
Facility
|
OP
|
$8.78
|
|
|
Service Code
|
NDC 6516263003
|
| Hospital Charge Code |
2500000587
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of VT Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.98
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna Commercial |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$8.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.95
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.95
|
| Rate for Payer: United Healthcare VA CCN |
$3.95
|
|
|
ITRACONAZOLE 100MG CAPSULE
|
Facility
|
OP
|
$8.78
|
|
| Hospital Charge Code |
2500000587
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of VT Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.98
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna Commercial |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$8.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.95
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.95
|
| Rate for Payer: United Healthcare VA CCN |
$3.95
|
|
|
ITRACONAZOLE 100MG CAPSULE
|
Facility
|
IP
|
$8.78
|
|
|
Service Code
|
NDC 6516263003
|
| Hospital Charge Code |
2500000587
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of VT Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.02
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna Commercial |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$8.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.46
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
|
|
IV CHEMO ADMN =<1HR INIT SBST
|
Facility
|
IP
|
$738.28
|
|
|
Service Code
|
CPT 96413
|
| Hospital Charge Code |
3359641301
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$546.40 |
| Max. Negotiated Rate |
$701.37 |
| Rate for Payer: Aetna of VT Commercial |
$701.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$546.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$546.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$627.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$620.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$590.62
|
| Rate for Payer: Cash Price |
$369.14
|
| Rate for Payer: Cigna Commercial |
$590.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$590.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$590.62
|
| Rate for Payer: Multiplan Commercial |
$686.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$627.54
|
| Rate for Payer: United Healthcare Commercial |
$701.37
|
|
|
IV CHEMO ADMN =<1HR INIT SBST
|
Facility
|
OP
|
$738.28
|
|
|
Service Code
|
CPT 96413
|
| Hospital Charge Code |
3359641301
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$326.98 |
| Max. Negotiated Rate |
$701.37 |
| Rate for Payer: Aetna of VT Commercial |
$701.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$661.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$326.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$661.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$444.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$627.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$598.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$332.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$586.93
|
| Rate for Payer: Cash Price |
$369.14
|
| Rate for Payer: Cigna Commercial |
$590.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$590.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$590.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$332.23
|
| Rate for Payer: Multiplan Commercial |
$686.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$627.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$332.23
|
| Rate for Payer: United Healthcare Commercial |
$701.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$332.23
|
| Rate for Payer: United Healthcare VA CCN |
$332.23
|
|
|
IV CHEMO ADMN EA ADDL HR
|
Facility
|
IP
|
$224.38
|
|
|
Service Code
|
CPT 96415
|
| Hospital Charge Code |
3359641501
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$166.06 |
| Max. Negotiated Rate |
$213.16 |
| Rate for Payer: Aetna of VT Commercial |
$213.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$166.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$166.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$190.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$179.50
|
| Rate for Payer: Cash Price |
$112.19
|
| Rate for Payer: Cigna Commercial |
$179.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$179.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$179.50
|
| Rate for Payer: Multiplan Commercial |
$208.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$190.72
|
| Rate for Payer: United Healthcare Commercial |
$213.16
|
|
|
IV CHEMO ADMN EA ADDL HR
|
Facility
|
OP
|
$224.38
|
|
|
Service Code
|
CPT 96415
|
| Hospital Charge Code |
3359641501
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$99.38 |
| Max. Negotiated Rate |
$213.16 |
| Rate for Payer: Aetna of VT Commercial |
$213.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$201.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$99.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$201.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$135.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$190.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$181.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$100.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$178.38
|
| Rate for Payer: Cash Price |
$112.19
|
| Rate for Payer: Cigna Commercial |
$179.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$179.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$179.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$100.97
|
| Rate for Payer: Multiplan Commercial |
$208.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$190.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$100.97
|
| Rate for Payer: United Healthcare Commercial |
$213.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.97
|
| Rate for Payer: United Healthcare VA CCN |
$100.97
|
|
|
IV CHEMO ADMN EA ADDL SEQL<1HR
|
Facility
|
OP
|
$279.18
|
|
|
Service Code
|
CPT 96417
|
| Hospital Charge Code |
3359641701
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$123.65 |
| Max. Negotiated Rate |
$265.22 |
| Rate for Payer: Aetna of VT Commercial |
$265.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$250.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$123.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$250.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$168.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$237.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$226.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$125.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$221.95
|
| Rate for Payer: Cash Price |
$139.59
|
| Rate for Payer: Cigna Commercial |
$223.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$223.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$223.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$125.63
|
| Rate for Payer: Multiplan Commercial |
$259.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$237.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$125.63
|
| Rate for Payer: United Healthcare Commercial |
$265.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$125.63
|
| Rate for Payer: United Healthcare VA CCN |
$125.63
|
|
|
IV CHEMO ADMN EA ADDL SEQL<1HR
|
Facility
|
IP
|
$279.18
|
|
|
Service Code
|
CPT 96417
|
| Hospital Charge Code |
3359641701
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$206.62 |
| Max. Negotiated Rate |
$265.22 |
| Rate for Payer: Aetna of VT Commercial |
$265.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$237.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$234.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$223.34
|
| Rate for Payer: Cash Price |
$139.59
|
| Rate for Payer: Cigna Commercial |
$223.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$223.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$223.34
|
| Rate for Payer: Multiplan Commercial |
$259.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$237.30
|
| Rate for Payer: United Healthcare Commercial |
$265.22
|
|
|
IV CHEMO ADMN PROLONG INF 8+HR
|
Facility
|
IP
|
$760.11
|
|
|
Service Code
|
CPT 96416
|
| Hospital Charge Code |
3359641601
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$562.56 |
| Max. Negotiated Rate |
$722.10 |
| Rate for Payer: Aetna of VT Commercial |
$722.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$562.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$562.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$646.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$638.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$608.09
|
| Rate for Payer: Cash Price |
$380.06
|
| Rate for Payer: Cigna Commercial |
$608.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$608.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$608.09
|
| Rate for Payer: Multiplan Commercial |
$706.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$646.09
|
| Rate for Payer: United Healthcare Commercial |
$722.10
|
|
|
IV CHEMO ADMN PROLONG INF 8+HR
|
Facility
|
OP
|
$760.11
|
|
|
Service Code
|
CPT 96416
|
| Hospital Charge Code |
3359641601
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$336.65 |
| Max. Negotiated Rate |
$722.10 |
| Rate for Payer: Aetna of VT Commercial |
$722.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$680.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$336.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$680.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$457.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$646.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$615.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$342.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$604.29
|
| Rate for Payer: Cash Price |
$380.06
|
| Rate for Payer: Cigna Commercial |
$608.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$608.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$608.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$342.05
|
| Rate for Payer: Multiplan Commercial |
$706.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$646.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$342.05
|
| Rate for Payer: United Healthcare Commercial |
$722.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$342.05
|
| Rate for Payer: United Healthcare VA CCN |
$342.05
|
|
|
IV CHEMO ADMN PUSH EA ADD SBST
|
Facility
|
OP
|
$432.67
|
|
|
Service Code
|
CPT 96411
|
| Hospital Charge Code |
3319641101
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$191.63 |
| Max. Negotiated Rate |
$411.04 |
| Rate for Payer: Aetna of VT Commercial |
$411.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$191.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$260.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$367.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$350.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$194.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$343.97
|
| Rate for Payer: Cash Price |
$216.34
|
| Rate for Payer: Cigna Commercial |
$346.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$346.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$346.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$194.70
|
| Rate for Payer: Multiplan Commercial |
$402.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$367.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$194.70
|
| Rate for Payer: United Healthcare Commercial |
$411.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$194.70
|
| Rate for Payer: United Healthcare VA CCN |
$194.70
|
|
|
IV CHEMO ADMN PUSH EA ADD SBST
|
Facility
|
IP
|
$432.67
|
|
|
Service Code
|
CPT 96411
|
| Hospital Charge Code |
3319641101
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$320.22 |
| Max. Negotiated Rate |
$411.04 |
| Rate for Payer: Aetna of VT Commercial |
$411.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$320.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$320.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$367.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$363.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$346.14
|
| Rate for Payer: Cash Price |
$216.34
|
| Rate for Payer: Cigna Commercial |
$346.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$346.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$346.14
|
| Rate for Payer: Multiplan Commercial |
$402.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$367.77
|
| Rate for Payer: United Healthcare Commercial |
$411.04
|
|
|
IV CHEMO ADMN PUSH INIT SBST
|
Facility
|
IP
|
$514.93
|
|
|
Service Code
|
CPT 96409
|
| Hospital Charge Code |
3319640901
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$381.10 |
| Max. Negotiated Rate |
$489.18 |
| Rate for Payer: Aetna of VT Commercial |
$489.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$381.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$381.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$437.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$432.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.94
|
| Rate for Payer: Cash Price |
$257.46
|
| Rate for Payer: Cigna Commercial |
$411.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.94
|
| Rate for Payer: Multiplan Commercial |
$478.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$437.69
|
| Rate for Payer: United Healthcare Commercial |
$489.18
|
|
|
IV CHEMO ADMN PUSH INIT SBST
|
Facility
|
OP
|
$514.93
|
|
|
Service Code
|
CPT 96409
|
| Hospital Charge Code |
3319640901
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$228.06 |
| Max. Negotiated Rate |
$489.18 |
| Rate for Payer: Aetna of VT Commercial |
$489.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$461.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$228.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$461.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$309.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$437.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$417.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$231.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$409.37
|
| Rate for Payer: Cash Price |
$257.46
|
| Rate for Payer: Cigna Commercial |
$411.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$411.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$411.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$231.72
|
| Rate for Payer: Multiplan Commercial |
$478.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$437.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$231.72
|
| Rate for Payer: United Healthcare Commercial |
$489.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.72
|
| Rate for Payer: United Healthcare VA CCN |
$231.72
|
|
|
IV CHEMO ADM SUBQ/IM NONHORMNL
|
Facility
|
IP
|
$210.15
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3319640101
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$155.53 |
| Max. Negotiated Rate |
$199.64 |
| Rate for Payer: Aetna of VT Commercial |
$199.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$155.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$155.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$178.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$176.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.12
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna Commercial |
$168.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.12
|
| Rate for Payer: Multiplan Commercial |
$195.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$178.63
|
| Rate for Payer: United Healthcare Commercial |
$199.64
|
|
|
IV CHEMO ADM SUBQ/IM NONHORMNL
|
Facility
|
OP
|
$210.15
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3319640101
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$199.64 |
| Rate for Payer: Aetna of VT Commercial |
$199.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$188.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$93.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$188.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$126.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$178.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$94.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$167.07
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna Commercial |
$168.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.57
|
| Rate for Payer: Multiplan Commercial |
$195.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$178.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.57
|
| Rate for Payer: United Healthcare Commercial |
$199.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.57
|
| Rate for Payer: United Healthcare VA CCN |
$94.57
|
|
