|
SMEAR WET MOUNT SALINE/INK
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
300872100
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$28.68 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.68
|
| 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 |
$28.68
|
| 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 |
$5.82
|
| Rate for Payer: United Healthcare VA CCN |
$0.01
|
|
|
SMEAR WET MOUNT SALINE/INK
|
Facility
|
OP
|
$28.95
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
3008721001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$28.68 |
| Rate for Payer: Aetna of VT Commercial |
$27.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.02
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cigna Commercial |
$23.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.16
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.03
|
| Rate for Payer: Multiplan Commercial |
$26.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.03
|
| Rate for Payer: United Healthcare Commercial |
$27.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.82
|
| Rate for Payer: United Healthcare VA CCN |
$13.03
|
|
|
SMEAR WET MOUNT SALINE/INK
|
Professional
|
Both
|
$28.95
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
3008721001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$28.68 |
| Rate for Payer: Aetna of VT Commercial |
$27.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$8.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$6.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.95
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cigna Commercial |
$7.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$26.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.82
|
| Rate for Payer: United Healthcare Commercial |
$8.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.82
|
| Rate for Payer: United Healthcare VA CCN |
$5.82
|
|
|
SMEAR WET MOUNT SALINE/INK
|
Facility
|
IP
|
$28.95
|
|
|
Service Code
|
CPT 87210
|
| Hospital Charge Code |
3008721001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Aetna of VT Commercial |
$27.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$21.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$21.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$24.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$24.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.16
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cigna Commercial |
$23.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$23.16
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$23.16
|
| Rate for Payer: Multiplan Commercial |
$26.92
|
| Rate for Payer: MVP Health Care of NY Commercial |
$24.61
|
| Rate for Payer: United Healthcare Commercial |
$27.50
|
|
|
SNAP DRESS KIT FOAM 15X15 CM
|
Facility
|
IP
|
$44.67
|
|
| Hospital Charge Code |
2720060801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.06 |
| Max. Negotiated Rate |
$42.44 |
| Rate for Payer: Aetna of VT Commercial |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$37.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$35.74
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cigna Commercial |
$35.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.74
|
| Rate for Payer: Multiplan Commercial |
$41.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.97
|
| Rate for Payer: United Healthcare Commercial |
$42.44
|
|
|
SNAP DRESS KIT FOAM 15X15 CM
|
Facility
|
OP
|
$44.67
|
|
| Hospital Charge Code |
2720060801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.78 |
| Max. Negotiated Rate |
$42.44 |
| Rate for Payer: Aetna of VT Commercial |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$26.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$37.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$35.51
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cigna Commercial |
$35.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$35.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$35.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$20.10
|
| Rate for Payer: Multiplan Commercial |
$41.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$20.10
|
| Rate for Payer: United Healthcare Commercial |
$42.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.10
|
| Rate for Payer: United Healthcare VA CCN |
$20.10
|
|
|
SODIUM CHLORIDE IRRIG 3000 ML
|
Facility
|
OP
|
$10.48
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
2500000597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$9.96 |
| Rate for Payer: Aetna of VT Commercial |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$9.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$6.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$8.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.33
|
| Rate for Payer: Cash Price |
$5.24
|
| Rate for Payer: Cigna Commercial |
$8.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.72
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4.72
|
| Rate for Payer: United Healthcare Commercial |
$9.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.72
|
| Rate for Payer: United Healthcare VA CCN |
$4.72
|
|
|
SODIUM CHLORIDE IRRIG 3000 ML
|
Facility
|
IP
|
$10.48
|
|
|
Service Code
|
NDC 990797208
|
| Hospital Charge Code |
2500000597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$9.96 |
| Rate for Payer: Aetna of VT Commercial |
$9.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$8.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.38
|
| Rate for Payer: Cash Price |
$5.24
|
| Rate for Payer: Cigna Commercial |
$8.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.38
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.91
|
| Rate for Payer: United Healthcare Commercial |
$9.96
|
|
|
SODIUM CHLRIDE IRRIG SOL 500ML
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 338004803
|
| Hospital Charge Code |
2500000583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna of VT Commercial |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.20
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
|
|
SODIUM CHLRIDE IRRIG SOL 500ML
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
2500000583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna of VT Commercial |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$7.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$5.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.54
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.40
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.40
|
| Rate for Payer: United Healthcare VA CCN |
$5.40
|
|
|
SODIUM CHLRIDE IRRIG SOL 500ML
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 338004803
|
| Hospital Charge Code |
2500000583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna of VT Commercial |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$5.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$10.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$7.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$5.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.54
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$5.40
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.40
|
| Rate for Payer: United Healthcare VA CCN |
$5.40
|
|
|
SODIUM CHLRIDE IRRIG SOL 500ML
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
2500000583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$11.40 |
| Rate for Payer: Aetna of VT Commercial |
$11.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$10.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$9.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$11.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.20
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
|
|
SODIUM ZIRCONIUM 10 GR PWDR PK
|
Facility
|
OP
|
$178.34
|
|
| Hospital Charge Code |
2500000577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.99 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: Aetna of VT Commercial |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$159.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$78.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$159.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$151.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$141.78
|
| Rate for Payer: Cash Price |
$89.17
|
| Rate for Payer: Cigna Commercial |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$142.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.25
|
| Rate for Payer: Multiplan Commercial |
$165.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$151.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.25
|
| Rate for Payer: United Healthcare Commercial |
$169.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.25
|
| Rate for Payer: United Healthcare VA CCN |
$80.25
|
|
|
SODIUM ZIRCONIUM 10 GR PWDR PK
|
Facility
|
IP
|
$178.34
|
|
| Hospital Charge Code |
2500000577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.99 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: Aetna of VT Commercial |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$131.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$131.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$151.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$142.67
|
| Rate for Payer: Cash Price |
$89.17
|
| Rate for Payer: Cigna Commercial |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$142.67
|
| Rate for Payer: Multiplan Commercial |
$165.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$151.59
|
| Rate for Payer: United Healthcare Commercial |
$169.42
|
|
|
SODIUM ZIRCONIUM 10 GR PWDR PK
|
Facility
|
IP
|
$178.34
|
|
|
Service Code
|
NDC 310111039
|
| Hospital Charge Code |
2500000577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.99 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: Aetna of VT Commercial |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$131.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$131.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$151.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$142.67
|
| Rate for Payer: Cash Price |
$89.17
|
| Rate for Payer: Cigna Commercial |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$142.67
|
| Rate for Payer: Multiplan Commercial |
$165.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$151.59
|
| Rate for Payer: United Healthcare Commercial |
$169.42
|
|
|
SODIUM ZIRCONIUM 10 GR PWDR PK
|
Facility
|
OP
|
$178.34
|
|
|
Service Code
|
NDC 310111039
|
| Hospital Charge Code |
2500000577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.99 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: Aetna of VT Commercial |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$159.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$78.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$159.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$107.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$151.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$144.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$80.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$141.78
|
| Rate for Payer: Cash Price |
$89.17
|
| Rate for Payer: Cigna Commercial |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$142.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$142.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.25
|
| Rate for Payer: Multiplan Commercial |
$165.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$151.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.25
|
| Rate for Payer: United Healthcare Commercial |
$169.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.25
|
| Rate for Payer: United Healthcare VA CCN |
$80.25
|
|
|
SPECIAL STAINS GROUP 1
|
Professional
|
Both
|
$205.73
|
|
|
Service Code
|
CPT 88312
|
| Hospital Charge Code |
3008831201
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$107.26 |
| Max. Negotiated Rate |
$421.10 |
| Rate for Payer: Aetna of VT Commercial |
$193.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$110.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$150.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$123.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$139.26
|
| Rate for Payer: Cash Price |
$102.86
|
| Rate for Payer: Cash Price |
$102.86
|
| Rate for Payer: Cigna Commercial |
$144.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$172.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$172.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$107.26
|
| Rate for Payer: Multiplan Commercial |
$191.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$107.26
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$107.26
|
| Rate for Payer: United Healthcare Commercial |
$165.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.26
|
| Rate for Payer: United Healthcare VA CCN |
$107.26
|
|
|
SPECIAL STAINS GROUP 1
|
Facility
|
OP
|
$205.73
|
|
|
Service Code
|
CPT 88312
|
| Hospital Charge Code |
3008831201
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$91.12 |
| Max. Negotiated Rate |
$421.10 |
| Rate for Payer: Aetna of VT Commercial |
$195.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$421.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$91.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$421.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$123.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$174.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$166.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$92.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$163.56
|
| Rate for Payer: Cash Price |
$102.86
|
| Rate for Payer: Cash Price |
$102.86
|
| Rate for Payer: Cigna Commercial |
$164.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$164.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$164.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$92.58
|
| Rate for Payer: Multiplan Commercial |
$191.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$174.87
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$92.58
|
| Rate for Payer: United Healthcare Commercial |
$195.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.26
|
| Rate for Payer: United Healthcare VA CCN |
$92.58
|
|
|
SPECIAL STAINS GROUP 1
|
Facility
|
IP
|
$205.73
|
|
|
Service Code
|
CPT 88312
|
| Hospital Charge Code |
3008831201
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$152.26 |
| Max. Negotiated Rate |
$195.44 |
| Rate for Payer: Aetna of VT Commercial |
$195.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$152.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$152.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$174.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$172.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$164.58
|
| Rate for Payer: Cash Price |
$102.86
|
| Rate for Payer: Cigna Commercial |
$164.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$164.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$164.58
|
| Rate for Payer: Multiplan Commercial |
$191.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$174.87
|
| Rate for Payer: United Healthcare Commercial |
$195.44
|
|
|
SPECIAL STAINS GROUP 2
|
Facility
|
IP
|
$235.63
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
3008831301
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$174.39 |
| Max. Negotiated Rate |
$223.85 |
| Rate for Payer: Aetna of VT Commercial |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$174.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$174.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$200.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$197.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.50
|
| Rate for Payer: Cash Price |
$117.82
|
| Rate for Payer: Cigna Commercial |
$188.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.50
|
| Rate for Payer: Multiplan Commercial |
$219.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.29
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
|
|
SPECIAL STAINS GROUP 2
|
Facility
|
OP
|
$235.63
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
3008831301
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$78.76 |
| Max. Negotiated Rate |
$345.27 |
| Rate for Payer: Aetna of VT Commercial |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$345.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$104.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$345.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$141.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$200.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$190.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$106.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$187.33
|
| Rate for Payer: Cash Price |
$117.82
|
| Rate for Payer: Cash Price |
$117.82
|
| Rate for Payer: Cigna Commercial |
$188.50
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$106.03
|
| Rate for Payer: Multiplan Commercial |
$219.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$200.29
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$106.03
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.76
|
| Rate for Payer: United Healthcare VA CCN |
$106.03
|
|
|
SPECIAL STAINS GROUP 2
|
Professional
|
Both
|
$235.63
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
3008831301
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$78.76 |
| Max. Negotiated Rate |
$345.27 |
| Rate for Payer: Aetna of VT Commercial |
$221.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$345.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$81.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$345.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$110.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$102.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$90.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$102.48
|
| Rate for Payer: Cash Price |
$117.82
|
| Rate for Payer: Cash Price |
$117.82
|
| Rate for Payer: Cigna Commercial |
$106.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$126.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$126.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$78.76
|
| Rate for Payer: Multiplan Commercial |
$219.14
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$78.76
|
| Rate for Payer: United Healthcare Commercial |
$121.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.76
|
| Rate for Payer: United Healthcare VA CCN |
$78.76
|
|
|
SPECIMEN INFECT AGNT CONCNTJ
|
Professional
|
Both
|
$76.66
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
3008701501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$72.06 |
| Rate for Payer: Aetna of VT Commercial |
$72.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$32.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$32.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$9.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$9.18
|
| Rate for Payer: Cash Price |
$38.33
|
| Rate for Payer: Cash Price |
$38.33
|
| Rate for Payer: Cigna Commercial |
$7.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.59
|
| Rate for Payer: Multiplan Commercial |
$71.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.68
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.68
|
| Rate for Payer: United Healthcare Commercial |
$10.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.68
|
| Rate for Payer: United Healthcare VA CCN |
$6.68
|
|
|
SPECIMEN INFECT AGNT CONCNTJ
|
Facility
|
IP
|
$76.66
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
3008701501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.74 |
| Max. Negotiated Rate |
$72.83 |
| Rate for Payer: Aetna of VT Commercial |
$72.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$56.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$56.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$64.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$61.33
|
| Rate for Payer: Cash Price |
$38.33
|
| Rate for Payer: Cigna Commercial |
$61.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.33
|
| Rate for Payer: Multiplan Commercial |
$71.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.16
|
| Rate for Payer: United Healthcare Commercial |
$72.83
|
|
|
SPECIMEN INFECT AGNT CONCNTJ
|
Facility
|
OP
|
$76.66
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
3008701501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$72.83 |
| Rate for Payer: Aetna of VT Commercial |
$72.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$32.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$33.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$32.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$65.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$34.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$60.94
|
| Rate for Payer: Cash Price |
$38.33
|
| Rate for Payer: Cash Price |
$38.33
|
| Rate for Payer: Cigna Commercial |
$61.33
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.33
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.33
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.50
|
| Rate for Payer: Multiplan Commercial |
$71.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$34.50
|
| Rate for Payer: United Healthcare Commercial |
$72.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.68
|
| Rate for Payer: United Healthcare VA CCN |
$34.50
|
|
