|
POSTPARTUM CARE ONLY SPX
|
Professional
|
Both
|
$403.00
|
|
|
Service Code
|
CPT 59430
|
| Hospital Charge Code |
9695943001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$159.68 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Aetna of VT Commercial |
$378.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$164.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$361.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$223.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$313.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$313.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$183.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$313.87
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$175.55
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$406.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$406.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$241.27
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,800.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$159.68
|
| Rate for Payer: United Healthcare Commercial |
$245.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$159.68
|
| Rate for Payer: United Healthcare VA CCN |
$159.68
|
|
|
POSTPARTUM CARE ONLY SPX
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
CPT 59430
|
| Hospital Charge Code |
9695943001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna of VT Commercial |
$382.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$298.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$342.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$338.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$322.40
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$322.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$322.40
|
| Rate for Payer: Multiplan Commercial |
$374.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$342.55
|
| Rate for Payer: United Healthcare Commercial |
$382.85
|
|
|
POTASSIUM CHLORIDE 40 MEQ/1,00
|
Facility
|
IP
|
$13.54
|
|
|
Service Code
|
NDC 338069504
|
| Hospital Charge Code |
636J348005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$12.86 |
| Rate for Payer: Aetna of VT Commercial |
$12.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$10.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$10.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$10.83
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Cigna Commercial |
$10.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$10.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$10.83
|
| Rate for Payer: Multiplan Commercial |
$12.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.51
|
| Rate for Payer: United Healthcare Commercial |
$12.86
|
|
|
POTASSIUM CHLORIDE 40 MEQ/1,00
|
Facility
|
OP
|
$13.54
|
|
|
Service Code
|
NDC 338069504
|
| Hospital Charge Code |
636J348005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$12.86 |
| Rate for Payer: Aetna of VT Commercial |
$12.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$8.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$10.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$6.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$10.76
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Cigna Commercial |
$10.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$10.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$10.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.09
|
| Rate for Payer: Multiplan Commercial |
$12.59
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.09
|
| Rate for Payer: United Healthcare Commercial |
$12.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.09
|
| Rate for Payer: United Healthcare VA CCN |
$6.09
|
|
|
POTASSIUM PHOSPHATE
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
2500000569
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
POTASSIUM PHOSPHATE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 6521905209
|
| Hospital Charge Code |
2500000569
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
POTASSIUM PHOSPHATE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 6521905209
|
| Hospital Charge Code |
2500000569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
POTASSIUM PHOSPHATE
|
Facility
|
IP
|
$0.01
|
|
| Hospital Charge Code |
2500000569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
POTASSIUM URINE
|
Facility
|
OP
|
$76.83
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
3008413301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$72.99 |
| Rate for Payer: Aetna of VT Commercial |
$72.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$62.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$34.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$61.08
|
| Rate for Payer: Cash Price |
$38.42
|
| Rate for Payer: Cash Price |
$38.42
|
| Rate for Payer: Cigna Commercial |
$61.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.57
|
| Rate for Payer: Multiplan Commercial |
$71.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$34.57
|
| Rate for Payer: United Healthcare Commercial |
$72.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.73
|
| Rate for Payer: United Healthcare VA CCN |
$34.57
|
|
|
POTASSIUM URINE
|
Facility
|
IP
|
$76.83
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
3008413301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.86 |
| Max. Negotiated Rate |
$72.99 |
| Rate for Payer: Aetna of VT Commercial |
$72.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$56.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$56.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$64.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$61.46
|
| Rate for Payer: Cash Price |
$38.42
|
| Rate for Payer: Cigna Commercial |
$61.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.46
|
| Rate for Payer: Multiplan Commercial |
$71.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.31
|
| Rate for Payer: United Healthcare Commercial |
$72.99
|
|
|
PPPS, INITIAL VISIT
|
Professional
|
Both
|
$212.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043802
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$157.45 |
| Max. Negotiated Rate |
$255.10 |
| Rate for Payer: Aetna of VT Commercial |
$199.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$189.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$162.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$189.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$220.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.80
|
| Rate for Payer: Cash Price |
$106.00
|
| Rate for Payer: Cash Price |
$106.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$255.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$255.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.45
|
| Rate for Payer: Multiplan Commercial |
$197.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$223.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare Commercial |
$242.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare VA CCN |
$157.45
|
|
|
PPPS, INITIAL VISIT
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$157.45 |
| Max. Negotiated Rate |
$331.82 |
| Rate for Payer: Aetna of VT Commercial |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$316.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$162.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$316.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$220.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.80
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$255.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$255.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.45
|
| Rate for Payer: Multiplan Commercial |
$328.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$223.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare Commercial |
$242.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare VA CCN |
$157.45
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043802
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$156.90 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Aetna of VT Commercial |
$201.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$156.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$156.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$178.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$169.60
|
| Rate for Payer: Cash Price |
$106.00
|
| Rate for Payer: Cigna Commercial |
$169.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.60
|
| Rate for Payer: Multiplan Commercial |
$197.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.20
|
| Rate for Payer: United Healthcare Commercial |
$201.40
|
|
|
PPPS, INITIAL VISIT
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
5100043801
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$126.32 |
| Max. Negotiated Rate |
$255.10 |
| Rate for Payer: Aetna of VT Commercial |
$132.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$162.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$220.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.80
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$255.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$255.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.45
|
| Rate for Payer: Multiplan Commercial |
$131.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$223.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare Commercial |
$242.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare VA CCN |
$157.45
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
OP
|
$2,296.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
9830043801
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$1,016.90 |
| Max. Negotiated Rate |
$2,181.20 |
| Rate for Payer: Aetna of VT Commercial |
$2,181.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,056.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,016.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,056.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,382.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,951.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,859.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,033.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,825.32
|
| Rate for Payer: Cash Price |
$1,148.00
|
| Rate for Payer: Cigna Commercial |
$1,836.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,836.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,836.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,033.20
|
| Rate for Payer: Multiplan Commercial |
$2,135.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,951.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,033.20
|
| Rate for Payer: United Healthcare Commercial |
$2,181.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,033.20
|
| Rate for Payer: United Healthcare VA CCN |
$1,033.20
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
5100043801
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.45 |
| Max. Negotiated Rate |
$133.95 |
| Rate for Payer: Aetna of VT Commercial |
$133.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$84.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$114.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$63.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$112.09
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$112.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$112.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$112.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$63.45
|
| Rate for Payer: Multiplan Commercial |
$131.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$119.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$63.45
|
| Rate for Payer: United Healthcare Commercial |
$133.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.45
|
| Rate for Payer: United Healthcare VA CCN |
$63.45
|
|
|
PPPS, INITIAL VISIT
|
Professional
|
Both
|
$2,296.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
9830043801
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$157.45 |
| Max. Negotiated Rate |
$2,158.24 |
| Rate for Payer: Aetna of VT Commercial |
$2,158.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,056.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$162.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,056.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$220.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$181.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$214.80
|
| Rate for Payer: Cash Price |
$1,148.00
|
| Rate for Payer: Cash Price |
$1,148.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$255.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$255.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.45
|
| Rate for Payer: Multiplan Commercial |
$2,135.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$223.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare Commercial |
$242.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.45
|
| Rate for Payer: United Healthcare VA CCN |
$157.45
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043802
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$93.89 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Aetna of VT Commercial |
$201.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$189.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$93.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$189.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$180.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.54
|
| Rate for Payer: Cash Price |
$106.00
|
| Rate for Payer: Cigna Commercial |
$169.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$169.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$169.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$197.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$180.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$95.40
|
| Rate for Payer: United Healthcare Commercial |
$201.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$95.40
|
| Rate for Payer: United Healthcare VA CCN |
$95.40
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
IP
|
$2,296.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
9830043801
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$1,699.27 |
| Max. Negotiated Rate |
$2,181.20 |
| Rate for Payer: Aetna of VT Commercial |
$2,181.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,699.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,699.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,951.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,928.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,836.80
|
| Rate for Payer: Cash Price |
$1,148.00
|
| Rate for Payer: Cigna Commercial |
$1,836.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,836.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,836.80
|
| Rate for Payer: Multiplan Commercial |
$2,135.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,951.60
|
| Rate for Payer: United Healthcare Commercial |
$2,181.20
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
IP
|
$353.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$261.26 |
| Max. Negotiated Rate |
$335.35 |
| Rate for Payer: Aetna of VT Commercial |
$335.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$261.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$261.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$300.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$296.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$282.40
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cigna Commercial |
$282.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$282.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$282.40
|
| Rate for Payer: Multiplan Commercial |
$328.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$300.05
|
| Rate for Payer: United Healthcare Commercial |
$335.35
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
OP
|
$353.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
9600043801
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$156.34 |
| Max. Negotiated Rate |
$335.35 |
| Rate for Payer: Aetna of VT Commercial |
$335.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$316.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$316.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$212.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$300.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$285.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$158.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$280.63
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cigna Commercial |
$282.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$282.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$282.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$158.85
|
| Rate for Payer: Multiplan Commercial |
$328.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$300.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$158.85
|
| Rate for Payer: United Healthcare Commercial |
$335.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$158.85
|
| Rate for Payer: United Healthcare VA CCN |
$158.85
|
|
|
PPPS, INITIAL VISIT
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT G0438
|
| Hospital Charge Code |
5100043801
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.35 |
| Max. Negotiated Rate |
$133.95 |
| Rate for Payer: Aetna of VT Commercial |
$133.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$118.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$112.80
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$112.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$112.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$112.80
|
| Rate for Payer: Multiplan Commercial |
$131.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$119.85
|
| Rate for Payer: United Healthcare Commercial |
$133.95
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043901
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$105.41 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna of VT Commercial |
$226.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$213.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$105.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$213.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$143.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$202.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$192.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$107.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$189.21
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$190.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.10
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.10
|
| Rate for Payer: United Healthcare VA CCN |
$107.10
|
|
|
PPPS, SUBSEQ VISIT
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
9600043901
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$124.02 |
| Max. Negotiated Rate |
$223.72 |
| Rate for Payer: Aetna of VT Commercial |
$223.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$213.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$127.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$213.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$173.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$157.38
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$176.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare Commercial |
$190.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.03
|
| Rate for Payer: United Healthcare VA CCN |
$124.03
|
|
|
PPPS, SUBSEQ VISIT
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
CPT G0439
|
| Hospital Charge Code |
5100043901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Aetna of VT Commercial |
$90.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$79.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$76.00
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$76.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$76.00
|
| Rate for Payer: Multiplan Commercial |
$88.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$80.75
|
| Rate for Payer: United Healthcare Commercial |
$90.25
|
|
