|
ABORTION DILATION & CURETTAGE
|
Professional
|
Both
|
$977.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9605984001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$202.06 |
| Max. Negotiated Rate |
$918.38 |
| Rate for Payer: Aetna of VT Commercial |
$918.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$875.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$875.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$394.98
|
| Rate for Payer: Cash Price |
$488.50
|
| Rate for Payer: Cash Price |
$488.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.99
|
| Rate for Payer: Multiplan Commercial |
$908.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$286.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare Commercial |
$310.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare VA CCN |
$202.06
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
IP
|
$783.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9605984002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$579.50 |
| Max. Negotiated Rate |
$743.85 |
| Rate for Payer: Aetna of VT Commercial |
$743.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$579.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$579.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$665.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$657.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$626.40
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna Commercial |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$626.40
|
| Rate for Payer: Multiplan Commercial |
$728.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$665.55
|
| Rate for Payer: United Healthcare Commercial |
$743.85
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
5105984001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.92 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna of VT Commercial |
$184.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$85.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$116.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$154.23
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$155.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.30
|
| Rate for Payer: Multiplan Commercial |
$180.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.30
|
| Rate for Payer: United Healthcare Commercial |
$184.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.30
|
| Rate for Payer: United Healthcare VA CCN |
$87.30
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
5105984001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$143.58 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna of VT Commercial |
$184.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.20
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$155.20
|
| Rate for Payer: Multiplan Commercial |
$180.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.90
|
| Rate for Payer: United Healthcare Commercial |
$184.30
|
|
|
ABORTION DILATION & CURETTAGE
|
Professional
|
Both
|
$783.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9825984001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$202.06 |
| Max. Negotiated Rate |
$736.02 |
| Rate for Payer: Aetna of VT Commercial |
$736.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$394.98
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.99
|
| Rate for Payer: Multiplan Commercial |
$728.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$286.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare Commercial |
$310.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare VA CCN |
$202.06
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
IP
|
$977.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9605984001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$723.08 |
| Max. Negotiated Rate |
$928.15 |
| Rate for Payer: Aetna of VT Commercial |
$928.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$723.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$723.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$830.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$820.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$781.60
|
| Rate for Payer: Cash Price |
$488.50
|
| Rate for Payer: Cigna Commercial |
$781.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$781.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$781.60
|
| Rate for Payer: Multiplan Commercial |
$908.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$830.45
|
| Rate for Payer: United Healthcare Commercial |
$928.15
|
|
|
ABORTION DILATION & CURETTAGE
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
5105984001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.80 |
| Max. Negotiated Rate |
$394.98 |
| Rate for Payer: Aetna of VT Commercial |
$182.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$394.98
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.99
|
| Rate for Payer: Multiplan Commercial |
$180.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$286.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare Commercial |
$310.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare VA CCN |
$202.06
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
OP
|
$783.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9825984001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$346.79 |
| Max. Negotiated Rate |
$743.85 |
| Rate for Payer: Aetna of VT Commercial |
$743.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$346.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$471.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$665.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$634.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$352.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$622.49
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna Commercial |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$626.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$352.35
|
| Rate for Payer: Multiplan Commercial |
$728.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$665.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$352.35
|
| Rate for Payer: United Healthcare Commercial |
$743.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$352.35
|
| Rate for Payer: United Healthcare VA CCN |
$352.35
|
|
|
ABORTION DILATION & CURETTAGE
|
Professional
|
Both
|
$783.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9605984002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$202.06 |
| Max. Negotiated Rate |
$736.02 |
| Rate for Payer: Aetna of VT Commercial |
$736.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$394.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$394.98
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.25
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.25
|
| Rate for Payer: Martins Point Health Care Commercial |
$252.99
|
| Rate for Payer: Multiplan Commercial |
$728.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$286.93
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare Commercial |
$310.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.06
|
| Rate for Payer: United Healthcare VA CCN |
$202.06
|
|
|
ABORTION DILATION & CURETTAGE
|
Facility
|
OP
|
$783.00
|
|
|
Service Code
|
CPT 59840
|
| Hospital Charge Code |
9605984002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$346.79 |
| Max. Negotiated Rate |
$743.85 |
| Rate for Payer: Aetna of VT Commercial |
$743.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$346.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$701.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$471.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$665.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$634.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$352.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$622.49
|
| Rate for Payer: Cash Price |
$391.50
|
| Rate for Payer: Cigna Commercial |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$626.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$626.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$352.35
|
| Rate for Payer: Multiplan Commercial |
$728.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$665.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$352.35
|
| Rate for Payer: United Healthcare Commercial |
$743.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$352.35
|
| Rate for Payer: United Healthcare VA CCN |
$352.35
|
|
|
ABORTION DILATION & EVAC
|
Professional
|
Both
|
$1,003.00
|
|
|
Service Code
|
CPT 59841
|
| Hospital Charge Code |
9695984101
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$337.81 |
| Max. Negotiated Rate |
$942.82 |
| Rate for Payer: Aetna of VT Commercial |
$942.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$898.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$347.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$898.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$472.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$615.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$615.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$388.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$615.18
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cigna Commercial |
$370.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$661.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$661.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$388.24
|
| Rate for Payer: Multiplan Commercial |
$932.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$479.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$337.81
|
| Rate for Payer: United Healthcare Commercial |
$519.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$337.81
|
| Rate for Payer: United Healthcare VA CCN |
$337.81
|
|
|
ABORTION DILATION & EVAC
|
Facility
|
OP
|
$1,003.00
|
|
|
Service Code
|
CPT 59841
|
| Hospital Charge Code |
9695984101
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$444.23 |
| Max. Negotiated Rate |
$952.85 |
| Rate for Payer: Aetna of VT Commercial |
$952.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$898.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$444.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$898.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$603.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$852.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$812.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$451.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$797.38
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cigna Commercial |
$802.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$802.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$802.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$451.35
|
| Rate for Payer: Multiplan Commercial |
$932.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$852.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$451.35
|
| Rate for Payer: United Healthcare Commercial |
$952.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$451.35
|
| Rate for Payer: United Healthcare VA CCN |
$451.35
|
|
|
ABORTION DILATION & EVAC
|
Facility
|
IP
|
$1,003.00
|
|
|
Service Code
|
CPT 59841
|
| Hospital Charge Code |
9695984101
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$742.32 |
| Max. Negotiated Rate |
$952.85 |
| Rate for Payer: Aetna of VT Commercial |
$952.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$742.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$742.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$852.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$842.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$802.40
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cigna Commercial |
$802.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$802.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$802.40
|
| Rate for Payer: Multiplan Commercial |
$932.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$852.55
|
| Rate for Payer: United Healthcare Commercial |
$952.85
|
|
|
ACETABULAR SHELL 054 NO-HOLE T
|
Facility
|
IP
|
$1,342.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780073811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.40 |
| Max. Negotiated Rate |
$1,275.14 |
| Rate for Payer: Aetna of VT Commercial |
$1,275.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$993.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$993.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,140.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,127.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,073.80
|
| Rate for Payer: Cash Price |
$671.12
|
| Rate for Payer: Cigna Commercial |
$1,073.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,073.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,073.80
|
| Rate for Payer: Multiplan Commercial |
$1,248.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,140.91
|
| Rate for Payer: United Healthcare Commercial |
$1,275.14
|
|
|
ACETABULAR SHELL 054 NO-HOLE T
|
Facility
|
OP
|
$1,342.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780073811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$594.48 |
| Max. Negotiated Rate |
$1,275.14 |
| Rate for Payer: Aetna of VT Commercial |
$1,275.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,202.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$594.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,202.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$808.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,140.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,087.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$604.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,067.09
|
| Rate for Payer: Cash Price |
$671.12
|
| Rate for Payer: Cigna Commercial |
$1,073.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,073.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,073.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$604.01
|
| Rate for Payer: Multiplan Commercial |
$1,248.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,140.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$604.01
|
| Rate for Payer: United Healthcare Commercial |
$1,275.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$604.01
|
| Rate for Payer: United Healthcare VA CCN |
$604.01
|
|
|
ACETABULAR SHELL 058 NO HOLE T
|
Facility
|
IP
|
$1,245.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075171
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$921.42 |
| Max. Negotiated Rate |
$1,182.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,182.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$921.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$921.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,058.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,045.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$996.00
|
| Rate for Payer: Cash Price |
$622.50
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$996.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$996.00
|
| Rate for Payer: Multiplan Commercial |
$1,157.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,058.25
|
| Rate for Payer: United Healthcare Commercial |
$1,182.75
|
|
|
ACETABULAR SHELL 058 NO HOLE T
|
Facility
|
OP
|
$1,245.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075171
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$551.41 |
| Max. Negotiated Rate |
$1,182.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,182.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,115.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$551.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,115.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$749.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,058.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,008.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$560.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$989.77
|
| Rate for Payer: Cash Price |
$622.50
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$996.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$996.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$560.25
|
| Rate for Payer: Multiplan Commercial |
$1,157.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,058.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$560.25
|
| Rate for Payer: United Healthcare Commercial |
$1,182.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$560.25
|
| Rate for Payer: United Healthcare VA CCN |
$560.25
|
|
|
ACETABULAR SHELL 058 NOHOLE T
|
Facility
|
OP
|
$1,345.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.70 |
| Max. Negotiated Rate |
$1,277.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,277.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,204.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$595.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,204.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$809.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,143.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,089.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$605.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,069.28
|
| Rate for Payer: Cash Price |
$672.50
|
| Rate for Payer: Cigna Commercial |
$1,076.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,076.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,076.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$605.25
|
| Rate for Payer: Multiplan Commercial |
$1,250.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,143.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$605.25
|
| Rate for Payer: United Healthcare Commercial |
$1,277.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$605.25
|
| Rate for Payer: United Healthcare VA CCN |
$605.25
|
|
|
ACETABULAR SHELL 058 NOHOLE T
|
Facility
|
IP
|
$1,345.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780075101
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.43 |
| Max. Negotiated Rate |
$1,277.75 |
| Rate for Payer: Aetna of VT Commercial |
$1,277.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$995.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$995.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,143.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,129.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,076.00
|
| Rate for Payer: Cash Price |
$672.50
|
| Rate for Payer: Cigna Commercial |
$1,076.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,076.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,076.00
|
| Rate for Payer: Multiplan Commercial |
$1,250.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,143.25
|
| Rate for Payer: United Healthcare Commercial |
$1,277.75
|
|
|
ACETABULAR SHELL O50 NO-HOLE T
|
Facility
|
IP
|
$1,690.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780073981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.77 |
| Max. Negotiated Rate |
$1,605.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,605.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,250.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,250.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,436.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,419.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,352.00
|
| Rate for Payer: Cash Price |
$845.00
|
| Rate for Payer: Cigna Commercial |
$1,352.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,352.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,352.00
|
| Rate for Payer: Multiplan Commercial |
$1,571.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,436.50
|
| Rate for Payer: United Healthcare Commercial |
$1,605.50
|
|
|
ACETABULAR SHELL O50 NO-HOLE T
|
Facility
|
OP
|
$1,690.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780073981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$748.50 |
| Max. Negotiated Rate |
$1,605.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,605.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,514.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$748.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,514.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,017.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,436.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,368.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$760.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,343.55
|
| Rate for Payer: Cash Price |
$845.00
|
| Rate for Payer: Cigna Commercial |
$1,352.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,352.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,352.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$760.50
|
| Rate for Payer: Multiplan Commercial |
$1,571.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,436.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$760.50
|
| Rate for Payer: United Healthcare Commercial |
$1,605.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$760.50
|
| Rate for Payer: United Healthcare VA CCN |
$760.50
|
|
|
ACETAMINOPHEN 120 MG SUPP
|
Professional
|
Both
|
$0.88
|
|
|
Service Code
|
NDC 4580273230
|
| Hospital Charge Code |
2500000016
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of VT Commercial |
$0.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.79
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$0.75
|
| Rate for Payer: United Healthcare VA CCN |
$0.35
|
|
|
ACETAMINOPHEN 120 MG SUPP
|
Professional
|
Both
|
$0.88
|
|
| Hospital Charge Code |
2500000016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of VT Commercial |
$0.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.79
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$0.75
|
| Rate for Payer: United Healthcare VA CCN |
$0.35
|
|
|
ACETAMINOPHEN 325 MG TAB
|
Professional
|
Both
|
$0.04
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
6370000001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of VT Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.04
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.02
|
|
|
ACETAMINOPHEN 325 MG TAB
|
Professional
|
Both
|
$0.04
|
|
| Hospital Charge Code |
6370000001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of VT Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.04
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.02
|
|
