|
ASSAY TEST FOR BLOOD FECAL
|
Facility
|
IP
|
$49.63
|
|
|
Service Code
|
CPT 82272
|
| Hospital Charge Code |
3008227201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$47.15 |
| Rate for Payer: Aetna of VT Commercial |
$47.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$36.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$36.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$42.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.70
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cigna Commercial |
$39.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.70
|
| Rate for Payer: Multiplan Commercial |
$46.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.19
|
| Rate for Payer: United Healthcare Commercial |
$47.15
|
|
|
ASSAY TEST FOR BLOOD FECAL
|
Professional
|
Both
|
$49.63
|
|
|
Service Code
|
CPT 82272
|
| Hospital Charge Code |
3008227201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$46.65 |
| Rate for Payer: Aetna of VT Commercial |
$46.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$4.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.00
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cigna Commercial |
$5.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$46.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4.23
|
| Rate for Payer: United Healthcare Commercial |
$6.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.23
|
| Rate for Payer: United Healthcare VA CCN |
$4.23
|
|
|
ASSAY TEST FOR BLOOD FECAL
|
Facility
|
OP
|
$49.63
|
|
|
Service Code
|
CPT 82272
|
| Hospital Charge Code |
3008227201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$47.15 |
| Rate for Payer: Aetna of VT Commercial |
$47.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$20.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$21.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$20.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$29.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$42.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$40.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$22.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$39.46
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cigna Commercial |
$39.70
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$39.70
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$39.70
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.33
|
| Rate for Payer: Multiplan Commercial |
$46.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$42.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.33
|
| Rate for Payer: United Healthcare Commercial |
$47.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.23
|
| Rate for Payer: United Healthcare VA CCN |
$22.33
|
|
|
ASSAY THYROID STIM HORMONE
|
Facility
|
IP
|
$193.66
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
3008444301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$143.33 |
| Max. Negotiated Rate |
$183.98 |
| Rate for Payer: Aetna of VT Commercial |
$183.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$143.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$143.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$154.93
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cigna Commercial |
$154.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$154.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$154.93
|
| Rate for Payer: Multiplan Commercial |
$180.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.61
|
| Rate for Payer: United Healthcare Commercial |
$183.98
|
|
|
ASSAY THYROID STIM HORMONE
|
Facility
|
OP
|
$193.66
|
|
|
Service Code
|
CPT 84443
|
| Hospital Charge Code |
3008444301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$183.98 |
| Rate for Payer: Aetna of VT Commercial |
$183.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$82.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$85.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$82.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$116.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$156.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$153.96
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cigna Commercial |
$154.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$154.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$154.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.15
|
| Rate for Payer: Multiplan Commercial |
$180.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.15
|
| Rate for Payer: United Healthcare Commercial |
$183.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.80
|
| Rate for Payer: United Healthcare VA CCN |
$87.15
|
|
|
ASSAY TRIIODOTHYRONINE (T3)
|
Facility
|
OP
|
$172.47
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
3008448001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$163.85 |
| Rate for Payer: Aetna of VT Commercial |
$163.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$69.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$76.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$69.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$103.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$146.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$77.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$137.11
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cigna Commercial |
$137.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$137.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$137.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$77.61
|
| Rate for Payer: Multiplan Commercial |
$160.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$77.61
|
| Rate for Payer: United Healthcare Commercial |
$163.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.18
|
| Rate for Payer: United Healthcare VA CCN |
$77.61
|
|
|
ASSAY TRIIODOTHYRONINE (T3)
|
Facility
|
IP
|
$172.47
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
3008448001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.65 |
| Max. Negotiated Rate |
$163.85 |
| Rate for Payer: Aetna of VT Commercial |
$163.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$127.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$127.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$146.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$137.98
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cigna Commercial |
$137.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$137.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$137.98
|
| Rate for Payer: Multiplan Commercial |
$160.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$146.60
|
| Rate for Payer: United Healthcare Commercial |
$163.85
|
|
|
ASSAY TRIIODOTHYRONINE (T3)
|
Professional
|
Both
|
$172.47
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
3008448001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$162.12 |
| Rate for Payer: Aetna of VT Commercial |
$162.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$69.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$69.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$16.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$24.23
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cigna Commercial |
$17.06
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$14.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$14.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$160.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$21.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.18
|
| Rate for Payer: United Healthcare VA CCN |
$14.18
|
|
|
ASSESSMENT OF APHASIA
|
Facility
|
OP
|
$415.67
|
|
|
Service Code
|
CPT 96105 GN
|
| Hospital Charge Code |
4409610501
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$184.10 |
| Max. Negotiated Rate |
$394.89 |
| Rate for Payer: Aetna of VT Commercial |
$394.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$372.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$184.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$372.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$250.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$353.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$336.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$187.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$330.46
|
| Rate for Payer: Cash Price |
$207.84
|
| Rate for Payer: Cigna Commercial |
$332.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$332.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$332.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$187.05
|
| Rate for Payer: Multiplan Commercial |
$386.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$232.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$187.05
|
| Rate for Payer: United Healthcare Commercial |
$394.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$187.05
|
| Rate for Payer: United Healthcare VA CCN |
$187.05
|
|
|
ASSESSMENT OF APHASIA
|
Facility
|
IP
|
$415.67
|
|
|
Service Code
|
CPT 96105 GN
|
| Hospital Charge Code |
4409610501
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$307.64 |
| Max. Negotiated Rate |
$394.89 |
| Rate for Payer: Aetna of VT Commercial |
$394.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$307.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$307.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$353.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$332.54
|
| Rate for Payer: Cash Price |
$207.84
|
| Rate for Payer: Cigna Commercial |
$332.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$332.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$332.54
|
| Rate for Payer: Multiplan Commercial |
$386.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$353.32
|
| Rate for Payer: United Healthcare Commercial |
$394.89
|
|
|
ASY HYDROXYPROGESTERONE 17-D
|
Facility
|
IP
|
$272.98
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
3008349801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.03 |
| Max. Negotiated Rate |
$259.33 |
| Rate for Payer: Aetna of VT Commercial |
$259.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$202.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$202.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$232.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$229.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$218.38
|
| Rate for Payer: Cash Price |
$136.49
|
| Rate for Payer: Cigna Commercial |
$218.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$218.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$218.38
|
| Rate for Payer: Multiplan Commercial |
$253.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$232.03
|
| Rate for Payer: United Healthcare Commercial |
$259.33
|
|
|
ASY HYDROXYPROGESTERONE 17-D
|
Facility
|
OP
|
$272.98
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
3008349801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$259.33 |
| Rate for Payer: Aetna of VT Commercial |
$259.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$133.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$120.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$133.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$164.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$232.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$221.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$122.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$217.02
|
| Rate for Payer: Cash Price |
$136.49
|
| Rate for Payer: Cash Price |
$136.49
|
| Rate for Payer: Cigna Commercial |
$218.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$218.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$218.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.84
|
| Rate for Payer: Multiplan Commercial |
$253.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$232.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$122.84
|
| Rate for Payer: United Healthcare Commercial |
$259.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.17
|
| Rate for Payer: United Healthcare VA CCN |
$122.84
|
|
|
ASY HYDROXYPROGESTERONE 17-D
|
Professional
|
Both
|
$272.98
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
3008349801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$256.60 |
| Rate for Payer: Aetna of VT Commercial |
$256.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$133.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$133.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$38.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$46.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$31.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$46.45
|
| Rate for Payer: Cash Price |
$136.49
|
| Rate for Payer: Cash Price |
$136.49
|
| Rate for Payer: Cigna Commercial |
$32.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$27.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$27.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$253.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$27.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.17
|
| Rate for Payer: United Healthcare Commercial |
$41.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.17
|
| Rate for Payer: United Healthcare VA CCN |
$27.17
|
|
|
ATOVAQUONE 750 MG/5ML PACK
|
Professional
|
Both
|
$72.30
|
|
| Hospital Charge Code |
2500000560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.92 |
| Max. Negotiated Rate |
$67.96 |
| Rate for Payer: Aetna of VT Commercial |
$67.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.77
|
| Rate for Payer: Cash Price |
$36.15
|
| Rate for Payer: Multiplan Commercial |
$67.24
|
| Rate for Payer: United Healthcare Commercial |
$61.45
|
| Rate for Payer: United Healthcare VA CCN |
$28.92
|
|
|
ATOVAQUONE 750 MG/5ML PACK
|
Professional
|
Both
|
$72.30
|
|
|
Service Code
|
NDC 5026808611
|
| Hospital Charge Code |
2500000560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.92 |
| Max. Negotiated Rate |
$67.96 |
| Rate for Payer: Aetna of VT Commercial |
$67.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.77
|
| Rate for Payer: Cash Price |
$36.15
|
| Rate for Payer: Multiplan Commercial |
$67.24
|
| Rate for Payer: United Healthcare Commercial |
$61.45
|
| Rate for Payer: United Healthcare VA CCN |
$28.92
|
|
|
ATTEMPTED VBAC AFTER CARE
|
Facility
|
OP
|
$2,880.00
|
|
|
Service Code
|
CPT 59622
|
| Hospital Charge Code |
9695962201
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$1,275.55 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,736.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,580.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,275.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,580.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,733.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,332.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,296.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,289.60
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cigna Commercial |
$2,304.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,304.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,304.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,296.00
|
| Rate for Payer: Multiplan Commercial |
$2,678.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,448.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,296.00
|
| Rate for Payer: United Healthcare Commercial |
$2,736.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,296.00
|
| Rate for Payer: United Healthcare VA CCN |
$1,296.00
|
|
|
ATTEMPTED VBAC AFTER CARE
|
Professional
|
Both
|
$2,880.00
|
|
|
Service Code
|
CPT 59622
|
| Hospital Charge Code |
9695962201
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$1,236.21 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,707.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,580.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,273.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,580.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,730.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,874.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,874.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,421.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,874.94
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cigna Commercial |
$1,359.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,144.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,144.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,236.21
|
| Rate for Payer: Multiplan Commercial |
$2,678.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,800.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,236.21
|
| Rate for Payer: United Healthcare Commercial |
$1,901.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,236.21
|
| Rate for Payer: United Healthcare VA CCN |
$1,236.21
|
|
|
ATTEMPTED VBAC AFTER CARE
|
Facility
|
IP
|
$2,880.00
|
|
|
Service Code
|
CPT 59622
|
| Hospital Charge Code |
9695962201
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$2,131.49 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,736.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,131.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,131.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,448.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,419.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,304.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cigna Commercial |
$2,304.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,304.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,304.00
|
| Rate for Payer: Multiplan Commercial |
$2,678.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,448.00
|
| Rate for Payer: United Healthcare Commercial |
$2,736.00
|
|
|
ATTEMPTED VBAC DELIVERY
|
Professional
|
Both
|
$3,503.00
|
|
|
Service Code
|
CPT 59618
|
| Hospital Charge Code |
9695961801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$2,441.79 |
| Max. Negotiated Rate |
$4,204.43 |
| Rate for Payer: Aetna of VT Commercial |
$3,292.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,138.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,515.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,138.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,418.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,095.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,095.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,808.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,095.72
|
| Rate for Payer: Cash Price |
$1,751.50
|
| Rate for Payer: Cash Price |
$1,751.50
|
| Rate for Payer: Cash Price |
$1,751.50
|
| Rate for Payer: Cigna Commercial |
$2,685.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,204.43
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,204.43
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,441.79
|
| Rate for Payer: Multiplan Commercial |
$3,257.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,800.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,441.79
|
| Rate for Payer: United Healthcare Commercial |
$3,756.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,441.79
|
| Rate for Payer: United Healthcare VA CCN |
$2,441.79
|
|
|
ATTEMPTED VBAC DELIVERY
|
Facility
|
IP
|
$3,503.00
|
|
|
Service Code
|
CPT 59618
|
| Hospital Charge Code |
9695961801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$2,592.57 |
| Max. Negotiated Rate |
$3,327.85 |
| Rate for Payer: Aetna of VT Commercial |
$3,327.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,592.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,592.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,977.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,942.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,802.40
|
| Rate for Payer: Cash Price |
$1,751.50
|
| Rate for Payer: Cigna Commercial |
$2,802.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,802.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,802.40
|
| Rate for Payer: Multiplan Commercial |
$3,257.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,977.55
|
| Rate for Payer: United Healthcare Commercial |
$3,327.85
|
|
|
ATTEMPTED VBAC DELIVERY
|
Facility
|
OP
|
$3,503.00
|
|
|
Service Code
|
CPT 59618
|
| Hospital Charge Code |
9695961801
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$1,551.48 |
| Max. Negotiated Rate |
$3,327.85 |
| Rate for Payer: Aetna of VT Commercial |
$3,327.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,138.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,551.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,138.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,108.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,977.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,837.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,576.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,784.89
|
| Rate for Payer: Cash Price |
$1,751.50
|
| Rate for Payer: Cigna Commercial |
$2,802.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,802.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,802.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,576.35
|
| Rate for Payer: Multiplan Commercial |
$3,257.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,977.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,576.35
|
| Rate for Payer: United Healthcare Commercial |
$3,327.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,576.35
|
| Rate for Payer: United Healthcare VA CCN |
$1,576.35
|
|
|
ATTEMPTED VBAC DELIVERY ONLY
|
Facility
|
IP
|
$2,404.00
|
|
|
Service Code
|
CPT 59620
|
| Hospital Charge Code |
9695962001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$1,779.20 |
| Max. Negotiated Rate |
$2,283.80 |
| Rate for Payer: Aetna of VT Commercial |
$2,283.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,779.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,779.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,043.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,019.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,923.20
|
| Rate for Payer: Cash Price |
$1,202.00
|
| Rate for Payer: Cigna Commercial |
$1,923.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,923.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,923.20
|
| Rate for Payer: Multiplan Commercial |
$2,235.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,043.40
|
| Rate for Payer: United Healthcare Commercial |
$2,283.80
|
|
|
ATTEMPTED VBAC DELIVERY ONLY
|
Professional
|
Both
|
$2,404.00
|
|
|
Service Code
|
CPT 59620
|
| Hospital Charge Code |
9695962001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$830.21 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Aetna of VT Commercial |
$2,259.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,153.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$855.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,153.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,162.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,659.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,659.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$954.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,659.97
|
| Rate for Payer: Cash Price |
$1,202.00
|
| Rate for Payer: Cash Price |
$1,202.00
|
| Rate for Payer: Cash Price |
$1,202.00
|
| Rate for Payer: Cigna Commercial |
$911.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,447.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,447.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,106.00
|
| Rate for Payer: Multiplan Commercial |
$2,235.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,800.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$830.21
|
| Rate for Payer: United Healthcare Commercial |
$1,277.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$830.21
|
| Rate for Payer: United Healthcare VA CCN |
$830.21
|
|
|
ATTEMPTED VBAC DELIVERY ONLY
|
Facility
|
OP
|
$2,404.00
|
|
|
Service Code
|
CPT 59620
|
| Hospital Charge Code |
9695962001
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$1,064.73 |
| Max. Negotiated Rate |
$2,283.80 |
| Rate for Payer: Aetna of VT Commercial |
$2,283.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,153.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,064.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,153.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,447.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,043.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,947.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,081.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,911.18
|
| Rate for Payer: Cash Price |
$1,202.00
|
| Rate for Payer: Cigna Commercial |
$1,923.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,923.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,923.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,081.80
|
| Rate for Payer: Multiplan Commercial |
$2,235.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,043.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,081.80
|
| Rate for Payer: United Healthcare Commercial |
$2,283.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,081.80
|
| Rate for Payer: United Healthcare VA CCN |
$1,081.80
|
|
|
ATTENDANCE AT DELIVERY
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
CPT 99464
|
| Hospital Charge Code |
9879946401
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$118.70 |
| Max. Negotiated Rate |
$254.60 |
| Rate for Payer: Aetna of VT Commercial |
$254.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$240.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$118.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$240.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$161.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$227.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$217.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$120.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$213.06
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cigna Commercial |
$214.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$214.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$214.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$120.60
|
| Rate for Payer: Multiplan Commercial |
$249.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$227.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$120.60
|
| Rate for Payer: United Healthcare Commercial |
$254.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$120.60
|
| Rate for Payer: United Healthcare VA CCN |
$120.60
|
|
