|
OMENTAL FLAP INTRA-ABDOMINAL
|
Facility
|
IP
|
$1,463.00
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
9824990501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,082.77 |
| Max. Negotiated Rate |
$1,389.85 |
| Rate for Payer: Aetna of VT Commercial |
$1,389.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,082.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,082.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,243.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,228.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,170.40
|
| Rate for Payer: Cash Price |
$731.50
|
| Rate for Payer: Cigna Commercial |
$1,170.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,170.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,170.40
|
| Rate for Payer: Multiplan Commercial |
$1,360.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,243.55
|
| Rate for Payer: United Healthcare Commercial |
$1,389.85
|
|
|
OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$1,463.00
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
9824990501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$315.83 |
| Max. Negotiated Rate |
$1,375.22 |
| Rate for Payer: Aetna of VT Commercial |
$1,375.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,310.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$325.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,310.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$442.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$616.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$616.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$363.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$616.53
|
| Rate for Payer: Cash Price |
$731.50
|
| Rate for Payer: Cash Price |
$731.50
|
| Rate for Payer: Cigna Commercial |
$579.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$539.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$539.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$315.83
|
| Rate for Payer: Multiplan Commercial |
$1,360.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$448.48
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$315.83
|
| Rate for Payer: United Healthcare Commercial |
$485.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$315.83
|
| Rate for Payer: United Healthcare VA CCN |
$315.83
|
|
|
OMENTAL FLAP INTRA-ABDOMINAL
|
Facility
|
OP
|
$1,463.00
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
9824990501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$647.96 |
| Max. Negotiated Rate |
$1,389.85 |
| Rate for Payer: Aetna of VT Commercial |
$1,389.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,310.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$647.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,310.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$880.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,243.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,185.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$658.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,163.09
|
| Rate for Payer: Cash Price |
$731.50
|
| Rate for Payer: Cigna Commercial |
$1,170.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,170.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,170.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$658.35
|
| Rate for Payer: Multiplan Commercial |
$1,360.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,243.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$658.35
|
| Rate for Payer: United Healthcare Commercial |
$1,389.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$658.35
|
| Rate for Payer: United Healthcare VA CCN |
$658.35
|
|
|
OMNIPAQUE 300 50ML
|
Facility
|
OP
|
$251.07
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550022631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$238.52 |
| Rate for Payer: Aetna of VT Commercial |
$238.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$111.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$151.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$213.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$203.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$112.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$199.60
|
| Rate for Payer: Cash Price |
$125.53
|
| Rate for Payer: Cash Price |
$125.53
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.98
|
| Rate for Payer: Multiplan Commercial |
$233.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$213.41
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$112.98
|
| Rate for Payer: United Healthcare Commercial |
$238.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$112.98
|
| Rate for Payer: United Healthcare VA CCN |
$112.98
|
|
|
OMNIPAQUE 300 50ML
|
Facility
|
IP
|
$251.07
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550022631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.82 |
| Max. Negotiated Rate |
$238.52 |
| Rate for Payer: Aetna of VT Commercial |
$238.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$185.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$185.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$213.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$210.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$200.86
|
| Rate for Payer: Cash Price |
$125.53
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.86
|
| Rate for Payer: Multiplan Commercial |
$233.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$213.41
|
| Rate for Payer: United Healthcare Commercial |
$238.52
|
|
|
ONDANSETRON 4 MG ODT TAB
|
Professional
|
Both
|
$0.03
|
|
|
Service Code
|
NDC 1671420030
|
| Hospital Charge Code |
6370000013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
ONDANSETRON 4 MG ODT TAB
|
Professional
|
Both
|
$0.03
|
|
| Hospital Charge Code |
6370000013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.03
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
OPEN BX/EXC INGUINOFEM NODES
|
Facility
|
OP
|
$1,206.00
|
|
|
Service Code
|
CPT 38531
|
| Hospital Charge Code |
9823853101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$534.14 |
| Max. Negotiated Rate |
$1,145.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,145.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,080.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$534.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,080.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$726.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,025.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$976.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$542.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$958.77
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cigna Commercial |
$964.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$964.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$964.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$542.70
|
| Rate for Payer: Multiplan Commercial |
$1,121.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,025.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$542.70
|
| Rate for Payer: United Healthcare Commercial |
$1,145.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$542.70
|
| Rate for Payer: United Healthcare VA CCN |
$542.70
|
|
|
OPEN BX/EXC INGUINOFEM NODES
|
Professional
|
Both
|
$1,206.00
|
|
|
Service Code
|
CPT 38531
|
| Hospital Charge Code |
9823853101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$413.45 |
| Max. Negotiated Rate |
$1,133.64 |
| Rate for Payer: Aetna of VT Commercial |
$1,133.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,080.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$425.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,080.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$578.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$619.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$619.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$475.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$619.83
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cigna Commercial |
$756.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$698.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$698.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$413.46
|
| Rate for Payer: Multiplan Commercial |
$1,121.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$587.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$413.45
|
| Rate for Payer: United Healthcare Commercial |
$636.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$413.45
|
| Rate for Payer: United Healthcare VA CCN |
$413.45
|
|
|
OPEN BX/EXC INGUINOFEM NODES
|
Facility
|
IP
|
$1,206.00
|
|
|
Service Code
|
CPT 38531
|
| Hospital Charge Code |
9823853101
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$892.56 |
| Max. Negotiated Rate |
$1,145.70 |
| Rate for Payer: Aetna of VT Commercial |
$1,145.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$892.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$892.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,025.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,013.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$964.80
|
| Rate for Payer: Cash Price |
$603.00
|
| Rate for Payer: Cigna Commercial |
$964.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$964.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$964.80
|
| Rate for Payer: Multiplan Commercial |
$1,121.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,025.10
|
| Rate for Payer: United Healthcare Commercial |
$1,145.70
|
|
|
OPERATING ROOM MAJOR PER MIN
|
Facility
|
IP
|
$153.03
|
|
| Hospital Charge Code |
3600000001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$113.26 |
| Max. Negotiated Rate |
$145.38 |
| Rate for Payer: Aetna of VT Commercial |
$145.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$128.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$122.42
|
| Rate for Payer: Cash Price |
$76.52
|
| Rate for Payer: Cigna Commercial |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$122.42
|
| Rate for Payer: Multiplan Commercial |
$142.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.08
|
| Rate for Payer: United Healthcare Commercial |
$145.38
|
|
|
OPERATING ROOM MAJOR PER MIN
|
Facility
|
OP
|
$153.03
|
|
| Hospital Charge Code |
3600000001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$145.38 |
| Rate for Payer: Aetna of VT Commercial |
$145.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$137.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$137.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$92.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$123.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$68.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$121.66
|
| Rate for Payer: Cash Price |
$76.52
|
| Rate for Payer: Cigna Commercial |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$122.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.86
|
| Rate for Payer: Multiplan Commercial |
$142.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.86
|
| Rate for Payer: United Healthcare Commercial |
$145.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$68.86
|
| Rate for Payer: United Healthcare VA CCN |
$68.86
|
|
|
OPERATING ROOM MINOR PER MIN
|
Facility
|
IP
|
$153.03
|
|
| Hospital Charge Code |
3600000002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$113.26 |
| Max. Negotiated Rate |
$145.38 |
| Rate for Payer: Aetna of VT Commercial |
$145.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$113.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$113.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$128.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$122.42
|
| Rate for Payer: Cash Price |
$76.52
|
| Rate for Payer: Cigna Commercial |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$122.42
|
| Rate for Payer: Multiplan Commercial |
$142.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.08
|
| Rate for Payer: United Healthcare Commercial |
$145.38
|
|
|
OPERATING ROOM MINOR PER MIN
|
Facility
|
OP
|
$153.03
|
|
| Hospital Charge Code |
3600000002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$145.38 |
| Rate for Payer: Aetna of VT Commercial |
$145.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$137.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$137.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$92.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$130.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$123.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$68.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$121.66
|
| Rate for Payer: Cash Price |
$76.52
|
| Rate for Payer: Cigna Commercial |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$122.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$122.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$68.86
|
| Rate for Payer: Multiplan Commercial |
$142.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$68.86
|
| Rate for Payer: United Healthcare Commercial |
$145.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$68.86
|
| Rate for Payer: United Healthcare VA CCN |
$68.86
|
|
|
OPH US DX B-SCAN
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651201
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
OPH US DX B-SCAN
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$27.46 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna of VT Commercial |
$58.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$37.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.29
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$49.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.90
|
| Rate for Payer: Multiplan Commercial |
$57.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.90
|
| Rate for Payer: United Healthcare Commercial |
$58.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.90
|
| Rate for Payer: United Healthcare VA CCN |
$27.90
|
|
|
OPH US DX B-SCAN
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$77.84 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$47.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$64.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$52.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$69.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$73.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$73.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$45.76
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$64.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$70.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.75
|
| Rate for Payer: United Healthcare VA CCN |
$45.75
|
|
|
OPH US DX B-SCAN
|
Facility
|
IP
|
$150.96
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
4027651201
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$111.73 |
| Max. Negotiated Rate |
$143.41 |
| Rate for Payer: Aetna of VT Commercial |
$143.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$111.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$111.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.77
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cigna Commercial |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.77
|
| Rate for Payer: Multiplan Commercial |
$140.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.32
|
| Rate for Payer: United Healthcare Commercial |
$143.41
|
|
|
OPH US DX B-SCAN
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$45.75 |
| Max. Negotiated Rate |
$77.84 |
| Rate for Payer: Aetna of VT Commercial |
$58.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$47.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$64.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$52.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.50
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$69.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$73.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$73.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$45.76
|
| Rate for Payer: Multiplan Commercial |
$57.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$64.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$70.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.75
|
| Rate for Payer: United Healthcare VA CCN |
$45.75
|
|
|
OPH US DX B-SCAN
|
Facility
|
OP
|
$150.96
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
4027651201
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$66.86 |
| Max. Negotiated Rate |
$143.41 |
| Rate for Payer: Aetna of VT Commercial |
$143.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$66.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$77.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$90.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$122.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$67.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.01
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cigna Commercial |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.77
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.93
|
| Rate for Payer: Multiplan Commercial |
$140.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.93
|
| Rate for Payer: United Healthcare Commercial |
$143.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.93
|
| Rate for Payer: United Healthcare VA CCN |
$67.93
|
|
|
OPH US DX B-SCAN
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$45.89 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna of VT Commercial |
$58.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$45.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$45.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$52.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$52.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$49.60
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$49.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$49.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$49.60
|
| Rate for Payer: Multiplan Commercial |
$57.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.70
|
| Rate for Payer: United Healthcare Commercial |
$58.90
|
|
|
OPH US DX B-SCAN
|
Facility
|
OP
|
$150.96
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
4507651201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$66.86 |
| Max. Negotiated Rate |
$143.41 |
| Rate for Payer: Aetna of VT Commercial |
$143.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$135.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$66.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$135.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$90.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$122.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$67.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.01
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cigna Commercial |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.77
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.93
|
| Rate for Payer: Multiplan Commercial |
$140.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.93
|
| Rate for Payer: United Healthcare Commercial |
$143.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.93
|
| Rate for Payer: United Healthcare VA CCN |
$67.93
|
|
|
OPH US DX B-SCAN
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
9817651201
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
OPH US DX B-SCAN
|
Facility
|
IP
|
$150.96
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
4507651201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$111.73 |
| Max. Negotiated Rate |
$143.41 |
| Rate for Payer: Aetna of VT Commercial |
$143.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$111.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$111.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.77
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cigna Commercial |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.77
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.77
|
| Rate for Payer: Multiplan Commercial |
$140.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.32
|
| Rate for Payer: United Healthcare Commercial |
$143.41
|
|
|
OPIOIDS & OPIATE ANALOGS 1/2
|
Facility
|
IP
|
$29.31
|
|
|
Service Code
|
CPT 80362
|
| Hospital Charge Code |
3008036201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.69 |
| Max. Negotiated Rate |
$27.84 |
| Rate for Payer: Aetna of VT Commercial |
$27.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$21.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$21.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.45
|
| Rate for Payer: Cash Price |
$14.65
|
| Rate for Payer: Cigna Commercial |
$23.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.45
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.45
|
| Rate for Payer: Multiplan Commercial |
$27.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.91
|
| Rate for Payer: United Healthcare Commercial |
$27.84
|
|
