|
KA FEMORAL S5+ INST SET
|
Facility
|
IP
|
$78.56
|
|
| Hospital Charge Code |
2720074311
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.14 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna of VT Commercial |
$74.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$58.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$58.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$66.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$65.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.85
|
| Rate for Payer: Cash Price |
$39.28
|
| Rate for Payer: Cigna Commercial |
$62.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$62.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$62.85
|
| Rate for Payer: Multiplan Commercial |
$73.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.78
|
| Rate for Payer: United Healthcare Commercial |
$74.63
|
|
|
KA FEMORAL S5+ INST SET
|
Facility
|
OP
|
$78.56
|
|
| Hospital Charge Code |
2720074311
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna of VT Commercial |
$74.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$70.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$70.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$47.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$66.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$63.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$35.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.46
|
| Rate for Payer: Cash Price |
$39.28
|
| Rate for Payer: Cigna Commercial |
$62.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$62.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$62.85
|
| Rate for Payer: Martins Point Health Care Commercial |
$35.35
|
| Rate for Payer: Multiplan Commercial |
$73.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.35
|
| Rate for Payer: United Healthcare Commercial |
$74.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.35
|
| Rate for Payer: United Healthcare VA CCN |
$35.35
|
|
|
KA FEMORAL S6 INSTRUMENT SET
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2720075181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.21 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna of VT Commercial |
$76.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$68.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$67.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$64.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$64.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.00
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$68.00
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
|
|
KA FEMORAL S6 INSTRUMENT SET
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2720075181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.43 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna of VT Commercial |
$76.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$71.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$35.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$71.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$68.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$36.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$63.60
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$64.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$64.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$64.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$68.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$36.00
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.00
|
| Rate for Payer: United Healthcare VA CCN |
$36.00
|
|
|
KA FEM S2+ INSTRUMENT SET
|
Facility
|
IP
|
$110.63
|
|
| Hospital Charge Code |
2720073771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.88 |
| Max. Negotiated Rate |
$105.10 |
| Rate for Payer: Aetna of VT Commercial |
$105.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$81.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$81.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$94.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$88.50
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna Commercial |
$88.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.50
|
| Rate for Payer: Multiplan Commercial |
$102.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.04
|
| Rate for Payer: United Healthcare Commercial |
$105.10
|
|
|
KA FEM S2+ INSTRUMENT SET
|
Facility
|
OP
|
$110.63
|
|
| Hospital Charge Code |
2720073771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$105.10 |
| Rate for Payer: Aetna of VT Commercial |
$105.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$49.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$66.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$94.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.95
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna Commercial |
$88.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$49.78
|
| Rate for Payer: Multiplan Commercial |
$102.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.78
|
| Rate for Payer: United Healthcare Commercial |
$105.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.78
|
| Rate for Payer: United Healthcare VA CCN |
$49.78
|
|
|
KETAMINE AND NORKETAMINE
|
Professional
|
Both
|
$170.83
|
|
|
Service Code
|
CPT 80357
|
| Hospital Charge Code |
3008035701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$384.32 |
| Rate for Payer: Aetna of VT Commercial |
$160.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Cash Price |
$85.42
|
| Rate for Payer: Cash Price |
$85.42
|
| Rate for Payer: Cigna Commercial |
$29.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$384.32
|
| Rate for Payer: Multiplan Commercial |
$158.87
|
| Rate for Payer: United Healthcare Commercial |
$145.21
|
| Rate for Payer: United Healthcare VA CCN |
$68.33
|
|
|
KETAMINE AND NORKETAMINE
|
Facility
|
OP
|
$170.83
|
|
|
Service Code
|
CPT 80357
|
| Hospital Charge Code |
3008035701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.66 |
| Max. Negotiated Rate |
$162.29 |
| Rate for Payer: Aetna of VT Commercial |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$75.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$102.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$76.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$135.81
|
| Rate for Payer: Cash Price |
$85.42
|
| Rate for Payer: Cash Price |
$85.42
|
| Rate for Payer: Cigna Commercial |
$136.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$136.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$136.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$76.87
|
| Rate for Payer: Multiplan Commercial |
$158.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$76.87
|
| Rate for Payer: United Healthcare Commercial |
$162.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.87
|
| Rate for Payer: United Healthcare VA CCN |
$76.87
|
|
|
KETAMINE AND NORKETAMINE
|
Facility
|
IP
|
$170.83
|
|
|
Service Code
|
CPT 80357
|
| Hospital Charge Code |
3008035701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.43 |
| Max. Negotiated Rate |
$162.29 |
| Rate for Payer: Aetna of VT Commercial |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$143.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$136.66
|
| Rate for Payer: Cash Price |
$85.42
|
| Rate for Payer: Cigna Commercial |
$136.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$136.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$136.66
|
| Rate for Payer: Multiplan Commercial |
$158.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.21
|
| Rate for Payer: United Healthcare Commercial |
$162.29
|
|
|
KETOCONAZOLE SHAMPOO KETO
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 713059204
|
| Hospital Charge Code |
2500000562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
KETOCONAZOLE SHAMPOO KETO
|
Facility
|
IP
|
$0.01
|
|
| Hospital Charge Code |
2500000562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
KETOCONAZOLE SHAMPOO KETO
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
2500000562
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
KETOCONAZOLE SHAMPOO KETO
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 713059204
|
| Hospital Charge Code |
2500000562
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
KETONE BODIES SERUM QUANTITATV
|
Professional
|
Both
|
$120.98
|
|
|
Service Code
|
CPT 82010
|
| Hospital Charge Code |
3008201001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$113.72 |
| Rate for Payer: Aetna of VT Commercial |
$113.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$11.23
|
| Rate for Payer: Cash Price |
$60.49
|
| Rate for Payer: Cash Price |
$60.49
|
| Rate for Payer: Cigna Commercial |
$9.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$112.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.17
|
| Rate for Payer: United Healthcare Commercial |
$12.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.17
|
| Rate for Payer: United Healthcare VA CCN |
$8.17
|
|
|
KETONE BODIES SERUM QUANTITATV
|
Facility
|
OP
|
$120.98
|
|
|
Service Code
|
CPT 82010
|
| Hospital Charge Code |
3008201001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$114.93 |
| Rate for Payer: Aetna of VT Commercial |
$114.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$97.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$54.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.18
|
| Rate for Payer: Cash Price |
$60.49
|
| Rate for Payer: Cash Price |
$60.49
|
| Rate for Payer: Cigna Commercial |
$96.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$96.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$96.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$54.44
|
| Rate for Payer: Multiplan Commercial |
$112.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$102.83
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$54.44
|
| Rate for Payer: United Healthcare Commercial |
$114.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.17
|
| Rate for Payer: United Healthcare VA CCN |
$54.44
|
|
|
KETONE BODIES SERUM QUANTITATV
|
Facility
|
IP
|
$120.98
|
|
|
Service Code
|
CPT 82010
|
| Hospital Charge Code |
3008201001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$89.54 |
| Max. Negotiated Rate |
$114.93 |
| Rate for Payer: Aetna of VT Commercial |
$114.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$89.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$89.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$101.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.78
|
| Rate for Payer: Cash Price |
$60.49
|
| Rate for Payer: Cigna Commercial |
$96.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$96.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$96.78
|
| Rate for Payer: Multiplan Commercial |
$112.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$102.83
|
| Rate for Payer: United Healthcare Commercial |
$114.93
|
|
|
KETOROLAC 15 MG/ML VIAL
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
|
|
KETOROLAC 15 MG/ML VIAL
|
Professional
|
Both
|
$0.03
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.35
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare VA CCN |
$0.30
|
|
|
KETOROLAC 30 MG/ML SYRINGE
|
Professional
|
Both
|
$11.52
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$10.83 |
| Rate for Payer: Aetna of VT Commercial |
$10.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.35
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$10.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare VA CCN |
$0.30
|
|
|
KETOROLAC 30 MG/ML VIAL
|
Professional
|
Both
|
$10.75
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$10.11 |
| Rate for Payer: Aetna of VT Commercial |
$10.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.35
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$10.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare VA CCN |
$0.30
|
|
|
KETOROLAC 30 MG/ML VIAL
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
|
|
KETOROLAC (IM USE ONLY) 60MG
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
|
|
KETOROLAC (IM USE ONLY) 60MG
|
Professional
|
Both
|
$11.93
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
636J188502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$11.21 |
| Rate for Payer: Aetna of VT Commercial |
$11.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.35
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$11.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.30
|
| Rate for Payer: United Healthcare VA CCN |
$0.30
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 78709
|
| Hospital Charge Code |
9727870901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$182.28 |
| Max. Negotiated Rate |
$1,185.08 |
| Rate for Payer: Aetna of VT Commercial |
$184.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,185.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$327.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,185.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$445.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$492.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$492.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$365.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$492.17
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$491.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$511.22
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$511.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$318.05
|
| Rate for Payer: Multiplan Commercial |
$182.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$318.06
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$318.06
|
| Rate for Payer: United Healthcare Commercial |
$489.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$318.06
|
| Rate for Payer: United Healthcare VA CCN |
$318.06
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 78709
|
| Hospital Charge Code |
9727870901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$145.06 |
| Max. Negotiated Rate |
$186.20 |
| Rate for Payer: Aetna of VT Commercial |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$145.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$145.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$166.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$164.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$156.80
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$156.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.80
|
| Rate for Payer: Multiplan Commercial |
$182.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$166.60
|
| Rate for Payer: United Healthcare Commercial |
$186.20
|
|
