|
LIDO-MPF 1% W/EPI 1:100,000
|
Facility
|
IP
|
$27.92
|
|
| Hospital Charge Code |
2500000175
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.66 |
| Max. Negotiated Rate |
$26.52 |
| Rate for Payer: Aetna of VT Commercial |
$26.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$23.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.34
|
| Rate for Payer: Cash Price |
$13.96
|
| Rate for Payer: Cigna Commercial |
$22.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$22.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$22.34
|
| Rate for Payer: Multiplan Commercial |
$25.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$23.73
|
| Rate for Payer: United Healthcare Commercial |
$26.52
|
|
|
LIGATE OVIDUCT(S) ADD-ON
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
CPT 58611
|
| Hospital Charge Code |
9825861101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$195.76 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Aetna of VT Commercial |
$419.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$195.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$266.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$375.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$358.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$198.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$351.39
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$353.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$353.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$353.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$198.90
|
| Rate for Payer: Multiplan Commercial |
$411.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$375.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$198.90
|
| Rate for Payer: United Healthcare Commercial |
$419.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$198.90
|
| Rate for Payer: United Healthcare VA CCN |
$198.90
|
|
|
LIGATE OVIDUCT(S) ADD-ON
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
CPT 58611
|
| Hospital Charge Code |
9825861101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$327.12 |
| Max. Negotiated Rate |
$419.90 |
| Rate for Payer: Aetna of VT Commercial |
$419.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$327.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$327.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$375.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$371.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$353.60
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$353.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$353.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$353.60
|
| Rate for Payer: Multiplan Commercial |
$411.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$375.70
|
| Rate for Payer: United Healthcare Commercial |
$419.90
|
|
|
LIGATE OVIDUCT(S) ADD-ON
|
Professional
|
Both
|
$442.00
|
|
|
Service Code
|
CPT 58611
|
| Hospital Charge Code |
9825861101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$68.91 |
| Max. Negotiated Rate |
$415.48 |
| Rate for Payer: Aetna of VT Commercial |
$415.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$70.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$96.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$160.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$160.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$79.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$160.36
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$121.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$115.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$115.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.91
|
| Rate for Payer: Multiplan Commercial |
$411.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$97.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.91
|
| Rate for Payer: United Healthcare Commercial |
$106.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$68.91
|
| Rate for Payer: United Healthcare VA CCN |
$68.91
|
|
|
LIGATION OF HEMORRHOID(S)
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
9824622101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$266.18 |
| Max. Negotiated Rate |
$570.95 |
| Rate for Payer: Aetna of VT Commercial |
$570.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$538.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$266.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$538.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$361.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$510.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$486.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$270.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$477.80
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$480.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$270.45
|
| Rate for Payer: Multiplan Commercial |
$558.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$510.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$270.45
|
| Rate for Payer: United Healthcare Commercial |
$570.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$270.45
|
| Rate for Payer: United Healthcare VA CCN |
$270.45
|
|
|
LIGATION OF HEMORRHOID(S)
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
9824622101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$444.80 |
| Max. Negotiated Rate |
$570.95 |
| Rate for Payer: Aetna of VT Commercial |
$570.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$444.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$444.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$510.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$504.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$480.80
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$480.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$480.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$480.80
|
| Rate for Payer: Multiplan Commercial |
$558.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$510.85
|
| Rate for Payer: United Healthcare Commercial |
$570.95
|
|
|
LIGATION OF HEMORRHOID(S)
|
Professional
|
Both
|
$601.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
9824622101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$184.19 |
| Max. Negotiated Rate |
$564.94 |
| Rate for Payer: Aetna of VT Commercial |
$564.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$538.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$189.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$538.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$257.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$352.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$352.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$211.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.20
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$334.06
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$443.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$443.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$271.88
|
| Rate for Payer: Multiplan Commercial |
$558.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$261.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$184.19
|
| Rate for Payer: United Healthcare Commercial |
$283.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.19
|
| Rate for Payer: United Healthcare VA CCN |
$184.19
|
|
|
LILETTA, 52 MG
|
Professional
|
Both
|
$3,131.00
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
636J729701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$905.11 |
| Max. Negotiated Rate |
$2,943.14 |
| Rate for Payer: Aetna of VT Commercial |
$2,943.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,562.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,562.26
|
| Rate for Payer: Cash Price |
$1,565.50
|
| Rate for Payer: Cash Price |
$1,565.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$905.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$905.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,062.18
|
| Rate for Payer: Multiplan Commercial |
$2,911.83
|
| Rate for Payer: United Healthcare Commercial |
$2,661.35
|
| Rate for Payer: United Healthcare VA CCN |
$917.00
|
|
|
LILETTA, 52 MG
|
Facility
|
OP
|
$2,562.26
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
636J729701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,562.26 |
| Max. Negotiated Rate |
$2,562.26 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,562.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,562.26
|
|
|
LINEZOLID 600MG/300ML
|
Facility
|
OP
|
$372.12
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
636J202001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$353.51 |
| Rate for Payer: Aetna of VT Commercial |
$353.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$224.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$316.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$301.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$167.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$295.84
|
| Rate for Payer: Cash Price |
$186.06
|
| Rate for Payer: Cash Price |
$186.06
|
| Rate for Payer: Cigna Commercial |
$297.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$297.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$297.70
|
| Rate for Payer: Martins Point Health Care Commercial |
$167.45
|
| Rate for Payer: Multiplan Commercial |
$346.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$316.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$167.45
|
| Rate for Payer: United Healthcare Commercial |
$353.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$167.45
|
| Rate for Payer: United Healthcare VA CCN |
$167.45
|
|
|
LINEZOLID 600MG/300ML
|
Facility
|
IP
|
$372.12
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
636J202001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$275.41 |
| Max. Negotiated Rate |
$353.51 |
| Rate for Payer: Aetna of VT Commercial |
$353.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$275.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$275.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$316.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$312.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$297.70
|
| Rate for Payer: Cash Price |
$186.06
|
| Rate for Payer: Cigna Commercial |
$297.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$297.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$297.70
|
| Rate for Payer: Multiplan Commercial |
$346.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$316.30
|
| Rate for Payer: United Healthcare Commercial |
$353.51
|
|
|
LIPID PANEL
|
Facility
|
IP
|
$113.74
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
3008006101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.18 |
| Max. Negotiated Rate |
$108.05 |
| Rate for Payer: Aetna of VT Commercial |
$108.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$95.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$90.99
|
| Rate for Payer: Cash Price |
$56.87
|
| Rate for Payer: Cigna Commercial |
$90.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$90.99
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$90.99
|
| Rate for Payer: Multiplan Commercial |
$105.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.68
|
| Rate for Payer: United Healthcare Commercial |
$108.05
|
|
|
LIPID PANEL
|
Facility
|
OP
|
$113.74
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
3008006101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$108.05 |
| Rate for Payer: Aetna of VT Commercial |
$108.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$51.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$90.42
|
| Rate for Payer: Cash Price |
$56.87
|
| Rate for Payer: Cash Price |
$56.87
|
| Rate for Payer: Cigna Commercial |
$90.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$90.99
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$90.99
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.18
|
| Rate for Payer: Multiplan Commercial |
$105.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.68
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.18
|
| Rate for Payer: United Healthcare Commercial |
$108.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.39
|
| Rate for Payer: United Healthcare VA CCN |
$51.18
|
|
|
LIPID PANEL
|
Professional
|
Both
|
$113.74
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
3008006101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$106.92 |
| Rate for Payer: Aetna of VT Commercial |
$106.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.89
|
| Rate for Payer: Cash Price |
$56.87
|
| Rate for Payer: Cash Price |
$56.87
|
| Rate for Payer: Cigna Commercial |
$16.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$105.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.39
|
| Rate for Payer: United Healthcare Commercial |
$20.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.39
|
| Rate for Payer: United Healthcare VA CCN |
$13.39
|
|
|
LIPOPRO BLD ELECTROPHORETIC
|
Facility
|
OP
|
$344.79
|
|
|
Service Code
|
CPT 83700
|
| Hospital Charge Code |
3008370001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$327.55 |
| Rate for Payer: Aetna of VT Commercial |
$327.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$152.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$207.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$293.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$279.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$155.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$274.11
|
| Rate for Payer: Cash Price |
$172.40
|
| Rate for Payer: Cash Price |
$172.40
|
| Rate for Payer: Cigna Commercial |
$275.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$275.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$275.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$155.16
|
| Rate for Payer: Multiplan Commercial |
$320.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$293.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$155.16
|
| Rate for Payer: United Healthcare Commercial |
$327.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.26
|
| Rate for Payer: United Healthcare VA CCN |
$155.16
|
|
|
LIPOPRO BLD ELECTROPHORETIC
|
Professional
|
Both
|
$344.79
|
|
|
Service Code
|
CPT 83700
|
| Hospital Charge Code |
3008370001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$324.10 |
| Rate for Payer: Aetna of VT Commercial |
$324.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$15.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$19.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$19.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$12.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$19.25
|
| Rate for Payer: Cash Price |
$172.40
|
| Rate for Payer: Cash Price |
$172.40
|
| Rate for Payer: Cigna Commercial |
$13.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$11.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$11.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$11.10
|
| Rate for Payer: Multiplan Commercial |
$320.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.26
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$11.26
|
| Rate for Payer: United Healthcare Commercial |
$17.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.26
|
| Rate for Payer: United Healthcare VA CCN |
$11.26
|
|
|
LIPOPRO BLD ELECTROPHORETIC
|
Facility
|
IP
|
$344.79
|
|
|
Service Code
|
CPT 83700
|
| Hospital Charge Code |
3008370001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$255.18 |
| Max. Negotiated Rate |
$327.55 |
| Rate for Payer: Aetna of VT Commercial |
$327.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$255.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$255.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$293.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$289.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$275.83
|
| Rate for Payer: Cash Price |
$172.40
|
| Rate for Payer: Cigna Commercial |
$275.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$275.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$275.83
|
| Rate for Payer: Multiplan Commercial |
$320.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$293.07
|
| Rate for Payer: United Healthcare Commercial |
$327.55
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 54252625
|
| Hospital Charge Code |
2500000593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 54252625
|
| Hospital Charge Code |
2500000593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
LO-PRO LOCK SCR SS 2.7X12MM
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780074601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$148.02 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of VT Commercial |
$190.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$170.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$168.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$160.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$160.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$160.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$160.00
|
| Rate for Payer: Multiplan Commercial |
$186.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$170.00
|
| Rate for Payer: United Healthcare Commercial |
$190.00
|
|
|
LO-PRO LOCK SCR SS 2.7X12MM
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780074601
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$88.58 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of VT Commercial |
$190.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$179.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$88.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$179.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$120.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$170.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$90.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$159.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$160.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$160.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$160.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$186.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$170.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$90.00
|
| Rate for Payer: United Healthcare Commercial |
$190.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$90.00
|
| Rate for Payer: United Healthcare VA CCN |
$90.00
|
|
|
LORAZEPAM 2 MG/ML SYRINGE
|
Facility
|
IP
|
$15.16
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636J206003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of VT Commercial |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$11.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$11.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$12.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.13
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cigna Commercial |
$12.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.13
|
| Rate for Payer: Multiplan Commercial |
$14.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.89
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
|
|
LORAZEPAM 2 MG/ML SYRINGE
|
Facility
|
OP
|
$15.16
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
636J206003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of VT Commercial |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$12.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$6.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.05
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cigna Commercial |
$12.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.82
|
| Rate for Payer: Multiplan Commercial |
$14.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.82
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.82
|
| Rate for Payer: United Healthcare VA CCN |
$6.82
|
|
|
LOW BACK DISK SURGERY
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
CPT 63030
|
| Hospital Charge Code |
9826303001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$451.76 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Aetna of VT Commercial |
$969.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$913.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$451.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$913.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$614.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$867.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$826.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$459.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$810.90
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$816.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$816.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$816.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$459.00
|
| Rate for Payer: Multiplan Commercial |
$948.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$867.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$459.00
|
| Rate for Payer: United Healthcare Commercial |
$969.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$459.00
|
| Rate for Payer: United Healthcare VA CCN |
$459.00
|
|
|
LOW BACK DISK SURGERY
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
CPT 63030
|
| Hospital Charge Code |
9826303001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$754.90 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Aetna of VT Commercial |
$969.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$754.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$754.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$867.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$856.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$816.00
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$816.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$816.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$816.00
|
| Rate for Payer: Multiplan Commercial |
$948.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$867.00
|
| Rate for Payer: United Healthcare Commercial |
$969.00
|
|
