|
LOW BACK DISK SURGERY
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
CPT 63030
|
| Hospital Charge Code |
9826303001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$844.85 |
| Max. Negotiated Rate |
$2,266.40 |
| Rate for Payer: Aetna of VT Commercial |
$958.80
|
| 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 |
$870.20
|
| 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 |
$1,182.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,266.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,266.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$971.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,266.40
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$1,174.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,443.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,443.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$844.85
|
| Rate for Payer: Multiplan Commercial |
$948.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,199.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$844.85
|
| Rate for Payer: United Healthcare Commercial |
$1,299.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$844.85
|
| Rate for Payer: United Healthcare VA CCN |
$844.85
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Facility
|
OP
|
$2,569.00
|
|
|
Service Code
|
CPT 58542
|
| Hospital Charge Code |
9825854201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,137.81 |
| Max. Negotiated Rate |
$2,440.55 |
| Rate for Payer: Aetna of VT Commercial |
$2,440.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,301.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,137.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,301.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,546.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,183.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,080.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,156.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,042.36
|
| Rate for Payer: Cash Price |
$1,284.50
|
| Rate for Payer: Cigna Commercial |
$2,055.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,055.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,055.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,156.05
|
| Rate for Payer: Multiplan Commercial |
$2,389.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,183.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,156.05
|
| Rate for Payer: United Healthcare Commercial |
$2,440.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,156.05
|
| Rate for Payer: United Healthcare VA CCN |
$1,156.05
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Professional
|
Both
|
$2,569.00
|
|
|
Service Code
|
CPT 58542
|
| Hospital Charge Code |
9825854201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$770.23 |
| Max. Negotiated Rate |
$2,414.86 |
| Rate for Payer: Aetna of VT Commercial |
$2,414.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,301.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$793.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,301.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,078.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,247.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,247.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$885.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,247.27
|
| Rate for Payer: Cash Price |
$1,284.50
|
| Rate for Payer: Cash Price |
$1,284.50
|
| Rate for Payer: Cigna Commercial |
$1,361.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,284.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,284.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$770.23
|
| Rate for Payer: Multiplan Commercial |
$2,389.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,093.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$770.23
|
| Rate for Payer: United Healthcare Commercial |
$1,184.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$770.23
|
| Rate for Payer: United Healthcare VA CCN |
$770.23
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Facility
|
IP
|
$2,569.00
|
|
|
Service Code
|
CPT 58542
|
| Hospital Charge Code |
9825854201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,901.32 |
| Max. Negotiated Rate |
$2,440.55 |
| Rate for Payer: Aetna of VT Commercial |
$2,440.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,901.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,901.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,183.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,157.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,055.20
|
| Rate for Payer: Cash Price |
$1,284.50
|
| Rate for Payer: Cigna Commercial |
$2,055.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,055.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,055.20
|
| Rate for Payer: Multiplan Commercial |
$2,389.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,183.65
|
| Rate for Payer: United Healthcare Commercial |
$2,440.55
|
|
|
LUNG PERFUSION IMAGING
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 78580
|
| Hospital Charge Code |
9727858001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$97.65 |
| Max. Negotiated Rate |
$791.02 |
| Rate for Payer: Aetna of VT Commercial |
$98.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$791.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$210.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$791.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$285.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$310.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$310.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$234.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$310.97
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$315.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$328.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$328.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$204.18
|
| Rate for Payer: Multiplan Commercial |
$97.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$204.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$204.19
|
| Rate for Payer: United Healthcare Commercial |
$314.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$204.19
|
| Rate for Payer: United Healthcare VA CCN |
$204.19
|
|
|
LUNG PERFUSION IMAGING
|
Facility
|
OP
|
$1,708.17
|
|
|
Service Code
|
CPT 78580
|
| Hospital Charge Code |
3417858001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$756.55 |
| Max. Negotiated Rate |
$1,622.76 |
| Rate for Payer: Aetna of VT Commercial |
$1,622.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$791.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$756.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$791.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,028.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,451.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,383.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$768.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,358.00
|
| Rate for Payer: Cash Price |
$854.08
|
| Rate for Payer: Cash Price |
$854.08
|
| Rate for Payer: Cigna Commercial |
$1,366.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,366.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,366.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$768.68
|
| Rate for Payer: Multiplan Commercial |
$1,588.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,451.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$768.68
|
| Rate for Payer: United Healthcare Commercial |
$1,622.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$768.68
|
| Rate for Payer: United Healthcare VA CCN |
$768.68
|
|
|
LUNG PERFUSION IMAGING
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 78580
|
| Hospital Charge Code |
9727858001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna of VT Commercial |
$99.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$94.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$46.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$94.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$63.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$89.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$85.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$47.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$83.47
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$84.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$84.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$84.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$97.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$89.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$47.25
|
| Rate for Payer: United Healthcare Commercial |
$99.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.25
|
| Rate for Payer: United Healthcare VA CCN |
$47.25
|
|
|
LUNG PERFUSION IMAGING
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 78580
|
| Hospital Charge Code |
9727858001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna of VT Commercial |
$99.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$89.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$84.00
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$84.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$84.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$97.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$99.75
|
|
|
LUNG PERFUSION IMAGING
|
Facility
|
IP
|
$1,708.17
|
|
|
Service Code
|
CPT 78580
|
| Hospital Charge Code |
3417858001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,264.22 |
| Max. Negotiated Rate |
$1,622.76 |
| Rate for Payer: Aetna of VT Commercial |
$1,622.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,264.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,264.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,451.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,434.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,366.54
|
| Rate for Payer: Cash Price |
$854.08
|
| Rate for Payer: Cigna Commercial |
$1,366.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,366.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,366.54
|
| Rate for Payer: Multiplan Commercial |
$1,588.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,451.94
|
| Rate for Payer: United Healthcare Commercial |
$1,622.76
|
|
|
LUNG VENTILAT&PERFUS IMAGING
|
Facility
|
OP
|
$2,326.50
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
3417858201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,030.41 |
| Max. Negotiated Rate |
$2,210.18 |
| Rate for Payer: Aetna of VT Commercial |
$2,210.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,101.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,030.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,101.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,400.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,977.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,884.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,046.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,849.57
|
| Rate for Payer: Cash Price |
$1,163.25
|
| Rate for Payer: Cash Price |
$1,163.25
|
| Rate for Payer: Cigna Commercial |
$1,861.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,861.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,861.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,046.92
|
| Rate for Payer: Multiplan Commercial |
$2,163.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,977.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,046.92
|
| Rate for Payer: United Healthcare Commercial |
$2,210.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,046.92
|
| Rate for Payer: United Healthcare VA CCN |
$1,046.92
|
|
|
LUNG VENTILAT&PERFUS IMAGING
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
9727858201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$66.88 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna of VT Commercial |
$143.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$135.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$66.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$135.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$90.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$122.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$67.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.05
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.95
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.95
|
| Rate for Payer: United Healthcare Commercial |
$143.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.95
|
| Rate for Payer: United Healthcare VA CCN |
$67.95
|
|
|
LUNG VENTILAT&PERFUS IMAGING
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
9727858201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$111.76 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna of VT Commercial |
$143.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$111.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$111.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.80
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.80
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.35
|
| Rate for Payer: United Healthcare Commercial |
$143.45
|
|
|
LUNG VENTILAT&PERFUS IMAGING
|
Facility
|
IP
|
$2,326.50
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
3417858201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,721.84 |
| Max. Negotiated Rate |
$2,210.18 |
| Rate for Payer: Aetna of VT Commercial |
$2,210.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,721.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,721.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,977.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,954.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,861.20
|
| Rate for Payer: Cash Price |
$1,163.25
|
| Rate for Payer: Cigna Commercial |
$1,861.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,861.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,861.20
|
| Rate for Payer: Multiplan Commercial |
$2,163.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,977.53
|
| Rate for Payer: United Healthcare Commercial |
$2,210.18
|
|
|
LUNG VENTILAT&PERFUS IMAGING
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9727858201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$140.43 |
| Max. Negotiated Rate |
$677.47 |
| Rate for Payer: Aetna of VT Commercial |
$141.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.13
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$370.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.98
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$248.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare Commercial |
$383.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare VA CCN |
$248.98
|
|
|
LUPRON 11.25 MG
|
Professional
|
Both
|
$4,924.62
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.29 |
| Max. Negotiated Rate |
$4,629.14 |
| Rate for Payer: Aetna of VT Commercial |
$4,629.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$181.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$247.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$202.92
|
| Rate for Payer: Cash Price |
$2,462.31
|
| Rate for Payer: Cash Price |
$2,462.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$172.29
|
| Rate for Payer: Multiplan Commercial |
$4,579.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare Commercial |
$271.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare VA CCN |
$176.45
|
|
|
LUPRON 45 MG
|
Professional
|
Both
|
$968.30
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.29 |
| Max. Negotiated Rate |
$910.20 |
| Rate for Payer: Aetna of VT Commercial |
$910.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$181.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$247.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$202.92
|
| Rate for Payer: Cash Price |
$484.15
|
| Rate for Payer: Cash Price |
$484.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$172.29
|
| Rate for Payer: Multiplan Commercial |
$900.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare Commercial |
$271.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare VA CCN |
$176.45
|
|
|
LUPRON DEPOT 22.5 MG
|
Professional
|
Both
|
$461.08
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.29 |
| Max. Negotiated Rate |
$473.80 |
| Rate for Payer: Aetna of VT Commercial |
$433.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$181.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$247.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$202.92
|
| Rate for Payer: Cash Price |
$230.54
|
| Rate for Payer: Cash Price |
$230.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$180.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$180.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$172.29
|
| Rate for Payer: Multiplan Commercial |
$428.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare Commercial |
$271.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$176.45
|
| Rate for Payer: United Healthcare VA CCN |
$176.45
|
|
|
LUPRON DEPOT 22.5 MG
|
Facility
|
OP
|
$473.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636J921701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$473.80 |
| Max. Negotiated Rate |
$473.80 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$473.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$473.80
|
|
|
LYME DIS DNA AMP PROBE
|
Facility
|
IP
|
$379.48
|
|
|
Service Code
|
CPT 87476
|
| Hospital Charge Code |
3008747601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$280.85 |
| Max. Negotiated Rate |
$360.51 |
| Rate for Payer: Aetna of VT Commercial |
$360.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$280.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$280.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$322.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$318.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$303.58
|
| Rate for Payer: Cash Price |
$189.74
|
| Rate for Payer: Cigna Commercial |
$303.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$303.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$303.58
|
| Rate for Payer: Multiplan Commercial |
$352.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$322.56
|
| Rate for Payer: United Healthcare Commercial |
$360.51
|
|
|
LYME DIS DNA AMP PROBE
|
Facility
|
OP
|
$379.48
|
|
|
Service Code
|
CPT 87476
|
| Hospital Charge Code |
3008747601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$360.51 |
| Rate for Payer: Aetna of VT Commercial |
$360.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$168.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$228.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$322.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$307.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$170.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$301.69
|
| Rate for Payer: Cash Price |
$189.74
|
| Rate for Payer: Cash Price |
$189.74
|
| Rate for Payer: Cigna Commercial |
$303.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$303.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$303.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$170.77
|
| Rate for Payer: Multiplan Commercial |
$352.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$322.56
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$170.77
|
| Rate for Payer: United Healthcare Commercial |
$360.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$170.77
|
|
|
LYME DIS DNA AMP PROBE
|
Professional
|
Both
|
$379.48
|
|
|
Service Code
|
CPT 87476
|
| Hospital Charge Code |
3008747601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.60 |
| Max. Negotiated Rate |
$356.71 |
| Rate for Payer: Aetna of VT Commercial |
$356.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$59.98
|
| Rate for Payer: Cash Price |
$189.74
|
| Rate for Payer: Cash Price |
$189.74
|
| Rate for Payer: Cigna Commercial |
$42.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.60
|
| Rate for Payer: Multiplan Commercial |
$352.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare Commercial |
$53.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$35.09
|
|
|
LYME DISEASE ANTIBODY
|
Professional
|
Both
|
$108.95
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
3008661801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.79 |
| Max. Negotiated Rate |
$102.41 |
| Rate for Payer: Aetna of VT Commercial |
$102.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$29.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$29.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$19.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$29.10
|
| Rate for Payer: Cash Price |
$54.48
|
| Rate for Payer: Cash Price |
$54.48
|
| Rate for Payer: Cigna Commercial |
$20.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.03
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.03
|
| Rate for Payer: Martins Point Health Care Commercial |
$16.79
|
| Rate for Payer: Multiplan Commercial |
$101.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.03
|
| Rate for Payer: United Healthcare Commercial |
$26.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.03
|
| Rate for Payer: United Healthcare VA CCN |
$17.03
|
|
|
LYME DISEASE ANTIBODY
|
Facility
|
IP
|
$108.95
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
3008661801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of VT Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$80.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$92.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.16
|
| Rate for Payer: Cash Price |
$54.48
|
| Rate for Payer: Cigna Commercial |
$87.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$87.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$87.16
|
| Rate for Payer: Multiplan Commercial |
$101.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$92.61
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
|
|
LYME DISEASE ANTIBODY
|
Facility
|
OP
|
$108.95
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
3008661801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of VT Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$48.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$65.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$92.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$88.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$86.62
|
| Rate for Payer: Cash Price |
$54.48
|
| Rate for Payer: Cash Price |
$54.48
|
| Rate for Payer: Cigna Commercial |
$87.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$87.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$87.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$49.03
|
| Rate for Payer: Multiplan Commercial |
$101.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$92.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.03
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.03
|
| Rate for Payer: United Healthcare VA CCN |
$49.03
|
|
|
LYME DISEASE ANTIBODY
|
Professional
|
Both
|
$116.84
|
|
|
Service Code
|
CPT 86617
|
| Hospital Charge Code |
3008661701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.27 |
| Max. Negotiated Rate |
$109.83 |
| Rate for Payer: Aetna of VT Commercial |
$109.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$15.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$21.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$26.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.47
|
| Rate for Payer: Cash Price |
$58.42
|
| Rate for Payer: Cash Price |
$58.42
|
| Rate for Payer: Cigna Commercial |
$18.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$15.27
|
| Rate for Payer: Multiplan Commercial |
$108.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$15.49
|
| Rate for Payer: United Healthcare Commercial |
$23.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.49
|
| Rate for Payer: United Healthcare VA CCN |
$15.49
|
|
