|
RICKETTSIA ANTIBODY
|
Professional
|
Both
|
$141.66
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
3008675701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.08 |
| Max. Negotiated Rate |
$133.16 |
| Rate for Payer: Aetna of VT Commercial |
$133.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$19.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$27.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$33.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$33.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.07
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cigna Commercial |
$23.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$19.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$19.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$19.08
|
| Rate for Payer: Multiplan Commercial |
$131.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$19.35
|
| Rate for Payer: United Healthcare Commercial |
$29.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.35
|
| Rate for Payer: United Healthcare VA CCN |
$19.35
|
|
|
RICKETTSIA ANTIBODY
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
3008675701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
|
|
RICKETTSIA ANTIBODY
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
CPT 86757
|
| Hospital Charge Code |
3008675701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$95.35 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.35
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
RISANKIZUMAB-RZAA 600 MG
|
Facility
|
OP
|
$40,038.64
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
636J232701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$38,036.71 |
| Rate for Payer: Aetna of VT Commercial |
$38,036.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$17,733.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$24,103.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$34,032.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$32,431.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$18,017.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$31,830.72
|
| Rate for Payer: Cash Price |
$20,019.32
|
| Rate for Payer: Cash Price |
$20,019.32
|
| Rate for Payer: Cigna Commercial |
$32,030.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$32,030.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$32,030.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$18,017.39
|
| Rate for Payer: Multiplan Commercial |
$37,235.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$34,032.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$18,017.39
|
| Rate for Payer: United Healthcare Commercial |
$38,036.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,017.39
|
| Rate for Payer: United Healthcare VA CCN |
$18,017.39
|
|
|
RISANKIZUMAB-RZAA 600 MG
|
Facility
|
IP
|
$40,038.64
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
636J232701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29,632.60 |
| Max. Negotiated Rate |
$38,036.71 |
| Rate for Payer: Aetna of VT Commercial |
$38,036.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29,632.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29,632.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$34,032.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$33,632.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$32,030.91
|
| Rate for Payer: Cash Price |
$20,019.32
|
| Rate for Payer: Cigna Commercial |
$32,030.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$32,030.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$32,030.91
|
| Rate for Payer: Multiplan Commercial |
$37,235.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$34,032.84
|
| Rate for Payer: United Healthcare Commercial |
$38,036.71
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$33.13 |
| Max. Negotiated Rate |
$153.78 |
| Rate for Payer: Aetna of VT Commercial |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$100.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$100.85
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$40.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$153.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$153.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.45
|
| Rate for Payer: Multiplan Commercial |
$110.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.13
|
| Rate for Payer: United Healthcare Commercial |
$50.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.13
|
| Rate for Payer: United Healthcare VA CCN |
$33.13
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$88.07 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna of VT Commercial |
$113.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.20
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.20
|
| Rate for Payer: Multiplan Commercial |
$110.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.15
|
| Rate for Payer: United Healthcare Commercial |
$113.05
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
IP
|
$232.44
|
|
|
Service Code
|
CPT 97597 GO
|
| Hospital Charge Code |
4309759701
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$172.03 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna of VT Commercial |
$220.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$197.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.95
|
| Rate for Payer: Cash Price |
$116.22
|
| Rate for Payer: Cigna Commercial |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.95
|
| Rate for Payer: Multiplan Commercial |
$216.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$197.57
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
OP
|
$232.44
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
4509759701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$102.95 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna of VT Commercial |
$220.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$208.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$208.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$139.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$197.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$104.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.79
|
| Rate for Payer: Cash Price |
$116.22
|
| Rate for Payer: Cigna Commercial |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.95
|
| Rate for Payer: Martins Point Health Care Commercial |
$104.60
|
| Rate for Payer: Multiplan Commercial |
$216.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$197.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$104.60
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$104.60
|
| Rate for Payer: United Healthcare VA CCN |
$104.60
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
IP
|
$232.44
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
4509759701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$172.03 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna of VT Commercial |
$220.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$197.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.95
|
| Rate for Payer: Cash Price |
$116.22
|
| Rate for Payer: Cigna Commercial |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.95
|
| Rate for Payer: Multiplan Commercial |
$216.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$197.57
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Professional
|
Both
|
$184.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$33.13 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna of VT Commercial |
$172.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$100.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$100.85
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$40.52
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$153.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$153.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$95.45
|
| Rate for Payer: Multiplan Commercial |
$171.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.13
|
| Rate for Payer: United Healthcare Commercial |
$50.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.13
|
| Rate for Payer: United Healthcare VA CCN |
$33.13
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$136.18 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna of VT Commercial |
$174.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$136.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$156.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$154.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$147.20
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$171.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$156.40
|
| Rate for Payer: United Healthcare Commercial |
$174.80
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759701
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$52.71 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna of VT Commercial |
$113.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$71.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.61
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$95.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.55
|
| Rate for Payer: Multiplan Commercial |
$110.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.55
|
| Rate for Payer: United Healthcare Commercial |
$113.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.55
|
| Rate for Payer: United Healthcare VA CCN |
$53.55
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
OP
|
$232.44
|
|
|
Service Code
|
CPT 97597 GO
|
| Hospital Charge Code |
4309759701
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$102.95 |
| Max. Negotiated Rate |
$220.82 |
| Rate for Payer: Aetna of VT Commercial |
$220.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$208.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$208.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$139.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$197.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$188.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$104.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.79
|
| Rate for Payer: Cash Price |
$116.22
|
| Rate for Payer: Cigna Commercial |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$185.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$185.95
|
| Rate for Payer: Martins Point Health Care Commercial |
$104.60
|
| Rate for Payer: Multiplan Commercial |
$216.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$104.60
|
| Rate for Payer: United Healthcare Commercial |
$220.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$104.60
|
| Rate for Payer: United Healthcare VA CCN |
$104.60
|
|
|
RMVL DEVITAL TIS 20 CM/<
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
9819759702
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$81.49 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna of VT Commercial |
$174.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$81.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$110.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$156.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$82.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$146.28
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$147.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$171.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$156.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$82.80
|
| Rate for Payer: United Healthcare Commercial |
$174.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.80
|
| Rate for Payer: United Healthcare VA CCN |
$82.80
|
|
|
RMVL DEVITAL TIS ADDL 20CM/<
|
Facility
|
OP
|
$82.72
|
|
|
Service Code
|
CPT 97598 GO
|
| Hospital Charge Code |
4309759801
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.64 |
| Max. Negotiated Rate |
$78.58 |
| Rate for Payer: Aetna of VT Commercial |
$78.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$74.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$74.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$67.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$37.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$65.76
|
| Rate for Payer: Cash Price |
$41.36
|
| Rate for Payer: Cigna Commercial |
$66.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$66.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$66.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.22
|
| Rate for Payer: Multiplan Commercial |
$76.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$46.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.22
|
| Rate for Payer: United Healthcare Commercial |
$78.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.22
|
| Rate for Payer: United Healthcare VA CCN |
$37.22
|
|
|
RMVL DEVITAL TIS ADDL 20CM/<
|
Facility
|
IP
|
$82.72
|
|
|
Service Code
|
CPT 97598 GO
|
| Hospital Charge Code |
4309759801
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$61.22 |
| Max. Negotiated Rate |
$78.58 |
| Rate for Payer: Aetna of VT Commercial |
$78.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$61.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$61.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$70.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$69.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$66.18
|
| Rate for Payer: Cash Price |
$41.36
|
| Rate for Payer: Cigna Commercial |
$66.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$66.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$66.18
|
| Rate for Payer: Multiplan Commercial |
$76.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$70.31
|
| Rate for Payer: United Healthcare Commercial |
$78.58
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
9609760201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$90.35 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Aetna of VT Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$182.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$90.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$182.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$122.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$173.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$165.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$91.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.18
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$163.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$163.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$91.80
|
| Rate for Payer: Multiplan Commercial |
$189.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$173.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$91.80
|
| Rate for Payer: United Healthcare Commercial |
$193.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.80
|
| Rate for Payer: United Healthcare VA CCN |
$91.80
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
IP
|
$81.60
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
5109760201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.39 |
| Max. Negotiated Rate |
$77.52 |
| Rate for Payer: Aetna of VT Commercial |
$77.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$60.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$60.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$69.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$68.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$65.28
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$65.28
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$65.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$65.28
|
| Rate for Payer: Multiplan Commercial |
$75.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$69.36
|
| Rate for Payer: United Healthcare Commercial |
$77.52
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Professional
|
Both
|
$122.40
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
9609760202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$128.58 |
| Rate for Payer: Aetna of VT Commercial |
$115.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$109.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$109.66
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$99.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$102.98
|
| Rate for Payer: Multiplan Commercial |
$113.83
|
| Rate for Payer: United Healthcare Commercial |
$104.04
|
| Rate for Payer: United Healthcare VA CCN |
$48.96
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
IP
|
$122.40
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
9609760202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$90.59 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna of VT Commercial |
$116.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$90.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$90.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$97.92
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$97.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$97.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$97.92
|
| Rate for Payer: Multiplan Commercial |
$113.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$104.04
|
| Rate for Payer: United Healthcare Commercial |
$116.28
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Professional
|
Both
|
$81.60
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
5109760201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.64 |
| Max. Negotiated Rate |
$128.58 |
| Rate for Payer: Aetna of VT Commercial |
$76.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.11
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$99.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$128.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$128.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$102.98
|
| Rate for Payer: Multiplan Commercial |
$75.89
|
| Rate for Payer: United Healthcare Commercial |
$69.36
|
| Rate for Payer: United Healthcare VA CCN |
$32.64
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
OP
|
$81.60
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
5109760201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.14 |
| Max. Negotiated Rate |
$77.52 |
| Rate for Payer: Aetna of VT Commercial |
$77.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$69.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$66.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$36.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$64.87
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$65.28
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$65.28
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$65.28
|
| Rate for Payer: Martins Point Health Care Commercial |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$75.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$69.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$36.72
|
| Rate for Payer: United Healthcare Commercial |
$77.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.72
|
| Rate for Payer: United Healthcare VA CCN |
$36.72
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
9609760201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$150.98 |
| Max. Negotiated Rate |
$193.80 |
| Rate for Payer: Aetna of VT Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$150.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$150.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$173.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$171.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$163.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$163.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$163.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$163.20
|
| Rate for Payer: Multiplan Commercial |
$189.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$173.40
|
| Rate for Payer: United Healthcare Commercial |
$193.80
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRD
|
Facility
|
OP
|
$122.40
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
9609760202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$116.28 |
| Rate for Payer: Aetna of VT Commercial |
$116.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$109.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$54.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$109.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$73.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$55.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$97.31
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$97.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$97.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$97.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$55.08
|
| Rate for Payer: Multiplan Commercial |
$113.83
|
| Rate for Payer: MVP Health Care of NY Commercial |
$104.04
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$55.08
|
| Rate for Payer: United Healthcare Commercial |
$116.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55.08
|
| Rate for Payer: United Healthcare VA CCN |
$55.08
|
|
