|
PROLNG SVC O/P EA ADDL 30
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
CPT 99355
|
| Hospital Charge Code |
5109935501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.33 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: Aetna of VT Commercial |
$64.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$50.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$50.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$57.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$57.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$54.40
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$54.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$54.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$54.40
|
| Rate for Payer: Multiplan Commercial |
$63.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$57.80
|
| Rate for Payer: United Healthcare Commercial |
$64.60
|
|
|
PROLNG SVC O/P EA ADDL 30
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
CPT 99355
|
| Hospital Charge Code |
9609935501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$84.40 |
| Max. Negotiated Rate |
$198.34 |
| Rate for Payer: Aetna of VT Commercial |
$198.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$189.03
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Multiplan Commercial |
$196.23
|
| Rate for Payer: United Healthcare Commercial |
$179.35
|
| Rate for Payer: United Healthcare VA CCN |
$84.40
|
|
|
PROLNG SVC O/P EA ADDL 30
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 99355
|
| Hospital Charge Code |
9609935501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$93.45 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna of VT Commercial |
$200.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$93.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$179.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$170.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$94.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$167.75
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.95
|
| Rate for Payer: Multiplan Commercial |
$196.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.95
|
| Rate for Payer: United Healthcare Commercial |
$200.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.95
|
| Rate for Payer: United Healthcare VA CCN |
$94.95
|
|
|
PROLONG SERVICE W/O CONTACT
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT 99358
|
| Hospital Charge Code |
9829935801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$140.62 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Aetna of VT Commercial |
$180.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$140.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$161.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$152.00
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.00
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.50
|
| Rate for Payer: United Healthcare Commercial |
$180.50
|
|
|
PROLONG SERVICE W/O CONTACT
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
CPT 99358
|
| Hospital Charge Code |
9829935801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$84.15 |
| Max. Negotiated Rate |
$180.50 |
| Rate for Payer: Aetna of VT Commercial |
$180.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$84.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$114.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$161.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$153.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$85.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$151.05
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$161.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$180.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.50
|
| Rate for Payer: United Healthcare VA CCN |
$85.50
|
|
|
PROLONG SERVICE W/O CONTACT
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
CPT 99358
|
| Hospital Charge Code |
9829935801
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$178.60 |
| Rate for Payer: Aetna of VT Commercial |
$178.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$168.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$168.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.92
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$89.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$137.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$137.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$84.33
|
| Rate for Payer: Multiplan Commercial |
$176.70
|
| Rate for Payer: United Healthcare Commercial |
$161.50
|
| Rate for Payer: United Healthcare VA CCN |
$76.00
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 99359
|
| Hospital Charge Code |
9829935901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$130.26 |
| Max. Negotiated Rate |
$167.20 |
| Rate for Payer: Aetna of VT Commercial |
$167.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$130.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$130.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$149.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$140.80
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$140.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$140.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$140.80
|
| Rate for Payer: Multiplan Commercial |
$163.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$149.60
|
| Rate for Payer: United Healthcare Commercial |
$167.20
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Professional
|
Both
|
$176.00
|
|
|
Service Code
|
CPT 99359
|
| Hospital Charge Code |
9829935901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$35.85 |
| Max. Negotiated Rate |
$165.44 |
| Rate for Payer: Aetna of VT Commercial |
$165.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$81.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$81.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$81.30
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$37.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$35.85
|
| Rate for Payer: Multiplan Commercial |
$163.68
|
| Rate for Payer: United Healthcare Commercial |
$149.60
|
| Rate for Payer: United Healthcare VA CCN |
$70.40
|
|
|
PROLONG SERV W/O CONTACT ADD
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 99359
|
| Hospital Charge Code |
9829935901
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$77.95 |
| Max. Negotiated Rate |
$167.20 |
| Rate for Payer: Aetna of VT Commercial |
$167.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$77.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$157.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$105.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$149.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$142.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$79.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$139.92
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$140.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$140.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$140.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$79.20
|
| Rate for Payer: Multiplan Commercial |
$163.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$149.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$79.20
|
| Rate for Payer: United Healthcare Commercial |
$167.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$79.20
|
| Rate for Payer: United Healthcare VA CCN |
$79.20
|
|
|
PROLONG SVC IP/OBS 1ST HR
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 99356
|
| Hospital Charge Code |
9879935601
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$263.48 |
| Max. Negotiated Rate |
$338.20 |
| Rate for Payer: Aetna of VT Commercial |
$338.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$263.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$263.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$302.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$299.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$284.80
|
| Rate for Payer: Cash Price |
$178.00
|
| Rate for Payer: Cigna Commercial |
$284.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$284.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$284.80
|
| Rate for Payer: Multiplan Commercial |
$331.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$302.60
|
| Rate for Payer: United Healthcare Commercial |
$338.20
|
|
|
PROLONG SVC IP/OBS 1ST HR
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 99356
|
| Hospital Charge Code |
9879935601
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$142.40 |
| Max. Negotiated Rate |
$334.64 |
| Rate for Payer: Aetna of VT Commercial |
$334.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$318.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$318.94
|
| Rate for Payer: Cash Price |
$178.00
|
| Rate for Payer: Multiplan Commercial |
$331.08
|
| Rate for Payer: United Healthcare Commercial |
$302.60
|
| Rate for Payer: United Healthcare VA CCN |
$142.40
|
|
|
PROLONG SVC IP/OBS 1ST HR
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 99356
|
| Hospital Charge Code |
9879935601
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$157.67 |
| Max. Negotiated Rate |
$338.20 |
| Rate for Payer: Aetna of VT Commercial |
$338.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$318.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$157.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$318.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$214.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$302.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$288.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$160.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$283.02
|
| Rate for Payer: Cash Price |
$178.00
|
| Rate for Payer: Cigna Commercial |
$284.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$284.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$284.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$160.20
|
| Rate for Payer: Multiplan Commercial |
$331.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$302.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$160.20
|
| Rate for Payer: United Healthcare Commercial |
$338.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$160.20
|
| Rate for Payer: United Healthcare VA CCN |
$160.20
|
|
|
PROLONG SVC OP SETTING 1ST HR
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
9829935401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$162.08 |
| Max. Negotiated Rate |
$208.05 |
| Rate for Payer: Aetna of VT Commercial |
$208.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$162.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$162.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$186.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$183.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$175.20
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$175.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$175.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$175.20
|
| Rate for Payer: Multiplan Commercial |
$203.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$186.15
|
| Rate for Payer: United Healthcare Commercial |
$208.05
|
|
|
PROLONG SVC OP SETTING 1ST HR
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
9829935401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$97.00 |
| Max. Negotiated Rate |
$208.05 |
| Rate for Payer: Aetna of VT Commercial |
$208.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$97.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$131.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$186.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$177.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$98.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$174.10
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$175.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$175.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$175.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$98.55
|
| Rate for Payer: Multiplan Commercial |
$203.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$186.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare Commercial |
$208.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare VA CCN |
$98.55
|
|
|
PROLONG SVC OP SETTING 1ST HR
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
CPT 99354
|
| Hospital Charge Code |
9829935401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$87.60 |
| Max. Negotiated Rate |
$205.86 |
| Rate for Payer: Aetna of VT Commercial |
$205.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$196.20
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$203.67
|
| Rate for Payer: United Healthcare Commercial |
$186.15
|
| Rate for Payer: United Healthcare VA CCN |
$87.60
|
|
|
PROMED KIT
|
Facility
|
IP
|
$18.14
|
|
| Hospital Charge Code |
2720074781
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$17.23 |
| Rate for Payer: Aetna of VT Commercial |
$17.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$13.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$13.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$15.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$15.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$14.51
|
| Rate for Payer: Cash Price |
$9.07
|
| Rate for Payer: Cigna Commercial |
$14.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$14.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$14.51
|
| Rate for Payer: Multiplan Commercial |
$16.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.42
|
| Rate for Payer: United Healthcare Commercial |
$17.23
|
|
|
PROMED KIT
|
Facility
|
OP
|
$18.14
|
|
| Hospital Charge Code |
2720074781
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$17.23 |
| Rate for Payer: Aetna of VT Commercial |
$17.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$16.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$16.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$10.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$15.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$14.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$8.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$14.42
|
| Rate for Payer: Cash Price |
$9.07
|
| Rate for Payer: Cigna Commercial |
$14.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$14.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$14.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.16
|
| Rate for Payer: Multiplan Commercial |
$16.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.16
|
| Rate for Payer: United Healthcare Commercial |
$17.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.16
|
| Rate for Payer: United Healthcare VA CCN |
$8.16
|
|
|
PROMETHAZINE 25 MG/ML VIAL
|
Professional
|
Both
|
$10.75
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
636J255001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$10.11 |
| Rate for Payer: Aetna of VT Commercial |
$10.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.39
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$10.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2.95
|
| Rate for Payer: United Healthcare Commercial |
$4.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.95
|
| Rate for Payer: United Healthcare VA CCN |
$2.95
|
|
|
PROMETHAZINE 25 MG/ML VIAL
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
636J255001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.10
|
|
|
PROMETHAZINE 25MG SUPP SP
|
Facility
|
OP
|
$32.60
|
|
|
Service Code
|
NDC 9999999954
|
| Hospital Charge Code |
2500000256
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$30.97 |
| Rate for Payer: Aetna of VT Commercial |
$30.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.92
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Cigna Commercial |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.67
|
| Rate for Payer: Multiplan Commercial |
$30.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.67
|
| Rate for Payer: United Healthcare Commercial |
$30.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.67
|
| Rate for Payer: United Healthcare VA CCN |
$14.67
|
|
|
PROMETHAZINE 25MG SUPP SP
|
Facility
|
IP
|
$32.60
|
|
| Hospital Charge Code |
2500000256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$30.97 |
| Rate for Payer: Aetna of VT Commercial |
$30.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$27.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.08
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Cigna Commercial |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.08
|
| Rate for Payer: Multiplan Commercial |
$30.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.71
|
| Rate for Payer: United Healthcare Commercial |
$30.97
|
|
|
PROMETHAZINE 25MG SUPP SP
|
Facility
|
IP
|
$32.60
|
|
|
Service Code
|
NDC 9999999954
|
| Hospital Charge Code |
2500000256
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$30.97 |
| Rate for Payer: Aetna of VT Commercial |
$30.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$27.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.08
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Cigna Commercial |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.08
|
| Rate for Payer: Multiplan Commercial |
$30.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.71
|
| Rate for Payer: United Healthcare Commercial |
$30.97
|
|
|
PROMETHAZINE 25MG SUPP SP
|
Facility
|
OP
|
$32.60
|
|
| Hospital Charge Code |
2500000256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$30.97 |
| Rate for Payer: Aetna of VT Commercial |
$30.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$25.92
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Cigna Commercial |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.67
|
| Rate for Payer: Multiplan Commercial |
$30.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.67
|
| Rate for Payer: United Healthcare Commercial |
$30.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.67
|
| Rate for Payer: United Healthcare VA CCN |
$14.67
|
|
|
PROPANOLOL ER 60 MG PROP
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 527411637
|
| Hospital Charge Code |
2500000563
|
|
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
|
|
|
PROPANOLOL ER 60 MG PROP
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
2500000563
|
|
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
|
|
