|
TANGNTL BX SKIN SINGLE LES
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
9601110202
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$145.06 |
| Max. Negotiated Rate |
$186.20 |
| Rate for Payer: Aetna of VT Commercial |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$145.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$145.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$166.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$164.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$156.80
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$156.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.80
|
| Rate for Payer: Multiplan Commercial |
$182.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$166.60
|
| Rate for Payer: United Healthcare Commercial |
$186.20
|
|
|
TANGNTL BX SKIN SINGLE LES
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
9601110201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$281.24 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Aetna of VT Commercial |
$361.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$281.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$281.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$323.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$319.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$304.00
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$304.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$304.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$304.00
|
| Rate for Payer: Multiplan Commercial |
$353.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$323.00
|
| Rate for Payer: United Healthcare Commercial |
$361.00
|
|
|
TANGNTL BX SKIN SINGLE LES
|
Professional
|
Both
|
$380.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
9601110201
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$357.20 |
| Rate for Payer: Aetna of VT Commercial |
$357.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$340.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$340.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$149.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$149.82
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$39.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$152.24
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$152.24
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.31
|
| Rate for Payer: Multiplan Commercial |
$353.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$49.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.20
|
| Rate for Payer: United Healthcare Commercial |
$54.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.20
|
| Rate for Payer: United Healthcare VA CCN |
$35.20
|
|
|
TANGNTL BX SKIN SINGLE LES
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
5101110201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.94 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna of VT Commercial |
$175.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$165.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$81.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$165.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$111.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$157.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$83.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$147.07
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$148.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$148.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$148.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$83.25
|
| Rate for Payer: Multiplan Commercial |
$172.05
|
| Rate for Payer: MVP Health Care of NY Commercial |
$157.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$83.25
|
| Rate for Payer: United Healthcare Commercial |
$175.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.25
|
| Rate for Payer: United Healthcare VA CCN |
$83.25
|
|
|
TAP, 3.0MM, CAN
|
Facility
|
OP
|
$259.00
|
|
| Hospital Charge Code |
2720073801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$114.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$114.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$155.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$209.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$116.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.91
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$116.55
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare VA CCN |
$116.55
|
|
|
TAP, 3.0MM, CAN
|
Facility
|
IP
|
$259.00
|
|
| Hospital Charge Code |
2720073801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.69 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$217.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$207.20
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
|
|
TAU PHOSPHORYLATED EA
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
CPT 84393
|
| Hospital Charge Code |
3008439301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,332.18 |
| Max. Negotiated Rate |
$1,710.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,710.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,332.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,332.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,530.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,512.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,440.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,440.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,440.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,440.00
|
| Rate for Payer: Multiplan Commercial |
$1,674.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,530.00
|
| Rate for Payer: United Healthcare Commercial |
$1,710.00
|
|
|
TAU PHOSPHORYLATED EA
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
CPT 84393
|
| Hospital Charge Code |
3008439301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$797.22 |
| Max. Negotiated Rate |
$1,710.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,710.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,612.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$797.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,612.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,083.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,530.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,458.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$810.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,431.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,440.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,440.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,440.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$810.00
|
| Rate for Payer: Multiplan Commercial |
$1,674.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,530.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$810.00
|
| Rate for Payer: United Healthcare Commercial |
$1,710.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$810.00
|
| Rate for Payer: United Healthcare VA CCN |
$810.00
|
|
|
TAU PHOSPHORYLATED EA
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
CPT 84393
|
| Hospital Charge Code |
3008439301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$1,692.00 |
| Rate for Payer: Aetna of VT Commercial |
$1,692.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,612.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,612.62
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Multiplan Commercial |
$1,674.00
|
| Rate for Payer: United Healthcare Commercial |
$1,530.00
|
| Rate for Payer: United Healthcare VA CCN |
$720.00
|
|
|
TB TEST CELL IMMUN MEASURE
|
Professional
|
Both
|
$299.11
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
3008648001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.11 |
| Max. Negotiated Rate |
$305.41 |
| Rate for Payer: Aetna of VT Commercial |
$281.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$305.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$63.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$305.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$86.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$105.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$105.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$71.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.94
|
| Rate for Payer: Cash Price |
$149.56
|
| Rate for Payer: Cash Price |
$149.56
|
| Rate for Payer: Cigna Commercial |
$74.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$61.11
|
| Rate for Payer: Multiplan Commercial |
$278.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$61.98
|
| Rate for Payer: United Healthcare Commercial |
$95.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.98
|
| Rate for Payer: United Healthcare VA CCN |
$61.98
|
|
|
TB TEST CELL IMMUN MEASURE
|
Facility
|
OP
|
$299.11
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
3008648001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.98 |
| Max. Negotiated Rate |
$305.41 |
| Rate for Payer: Aetna of VT Commercial |
$284.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$305.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$305.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$180.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$254.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$242.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$134.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$237.79
|
| Rate for Payer: Cash Price |
$149.56
|
| Rate for Payer: Cash Price |
$149.56
|
| Rate for Payer: Cigna Commercial |
$239.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$239.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$239.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$134.60
|
| Rate for Payer: Multiplan Commercial |
$278.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$254.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$134.60
|
| Rate for Payer: United Healthcare Commercial |
$284.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.98
|
| Rate for Payer: United Healthcare VA CCN |
$134.60
|
|
|
TB TEST CELL IMMUN MEASURE
|
Facility
|
IP
|
$299.11
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
3008648001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$221.37 |
| Max. Negotiated Rate |
$284.15 |
| Rate for Payer: Aetna of VT Commercial |
$284.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$221.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$221.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$254.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$251.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$239.29
|
| Rate for Payer: Cash Price |
$149.56
|
| Rate for Payer: Cigna Commercial |
$239.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$239.29
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$239.29
|
| Rate for Payer: Multiplan Commercial |
$278.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$254.24
|
| Rate for Payer: United Healthcare Commercial |
$284.15
|
|
|
TC99M Ceretec WBC
|
Facility
|
OP
|
$5,525.92
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
343A952101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,447.43 |
| Max. Negotiated Rate |
$5,249.62 |
| Rate for Payer: Aetna of VT Commercial |
$5,249.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,950.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,447.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,950.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,326.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,697.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,476.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,486.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,393.11
|
| Rate for Payer: Cash Price |
$2,762.96
|
| Rate for Payer: Cigna Commercial |
$4,420.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,420.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,420.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,486.66
|
| Rate for Payer: Multiplan Commercial |
$5,139.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,697.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,486.66
|
| Rate for Payer: United Healthcare Commercial |
$5,249.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,486.66
|
| Rate for Payer: United Healthcare VA CCN |
$2,486.66
|
|
|
TC99M Ceretec WBC
|
Facility
|
IP
|
$5,525.92
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
343A952101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$4,089.73 |
| Max. Negotiated Rate |
$5,249.62 |
| Rate for Payer: Aetna of VT Commercial |
$5,249.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,089.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,089.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,697.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,641.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$4,420.74
|
| Rate for Payer: Cash Price |
$2,762.96
|
| Rate for Payer: Cigna Commercial |
$4,420.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$4,420.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$4,420.74
|
| Rate for Payer: Multiplan Commercial |
$5,139.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,697.03
|
| Rate for Payer: United Healthcare Commercial |
$5,249.62
|
|
|
TC99M DTPA (Pentetate)
|
Facility
|
IP
|
$559.55
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
343A953901
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$414.12 |
| Max. Negotiated Rate |
$531.57 |
| Rate for Payer: Aetna of VT Commercial |
$531.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$414.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$414.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$475.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$470.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$447.64
|
| Rate for Payer: Cash Price |
$279.78
|
| Rate for Payer: Cigna Commercial |
$447.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$447.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$447.64
|
| Rate for Payer: Multiplan Commercial |
$520.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$475.62
|
| Rate for Payer: United Healthcare Commercial |
$531.57
|
|
|
TC99M DTPA (Pentetate)
|
Facility
|
OP
|
$559.55
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
343A953901
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$247.82 |
| Max. Negotiated Rate |
$531.57 |
| Rate for Payer: Aetna of VT Commercial |
$531.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$501.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$247.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$501.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$336.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$475.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$453.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$251.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$444.84
|
| Rate for Payer: Cash Price |
$279.78
|
| Rate for Payer: Cigna Commercial |
$447.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$447.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$447.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$251.80
|
| Rate for Payer: Multiplan Commercial |
$520.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$475.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$251.80
|
| Rate for Payer: United Healthcare Commercial |
$531.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.80
|
| Rate for Payer: United Healthcare VA CCN |
$251.80
|
|
|
TC99 Mebrofenin
|
Facility
|
OP
|
$349.49
|
|
|
Service Code
|
HCPCS A4641
|
| Hospital Charge Code |
343A464101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$154.79 |
| Max. Negotiated Rate |
$332.02 |
| Rate for Payer: Aetna of VT Commercial |
$332.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$313.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$154.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$313.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$210.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$297.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$283.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$157.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$277.84
|
| Rate for Payer: Cash Price |
$174.74
|
| Rate for Payer: Cigna Commercial |
$279.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$279.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$279.59
|
| Rate for Payer: Martins Point Health Care Commercial |
$157.27
|
| Rate for Payer: Multiplan Commercial |
$325.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$297.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$157.27
|
| Rate for Payer: United Healthcare Commercial |
$332.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.27
|
| Rate for Payer: United Healthcare VA CCN |
$157.27
|
|
|
TC99 Mebrofenin
|
Facility
|
IP
|
$349.49
|
|
|
Service Code
|
HCPCS A4641
|
| Hospital Charge Code |
343A464101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$258.66 |
| Max. Negotiated Rate |
$332.02 |
| Rate for Payer: Aetna of VT Commercial |
$332.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$258.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$258.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$297.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$293.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$279.59
|
| Rate for Payer: Cash Price |
$174.74
|
| Rate for Payer: Cigna Commercial |
$279.59
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$279.59
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$279.59
|
| Rate for Payer: Multiplan Commercial |
$325.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$297.07
|
| Rate for Payer: United Healthcare Commercial |
$332.02
|
|
|
TC99M Labeled RBC
|
Facility
|
IP
|
$7,479.96
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
343A956001
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5,535.92 |
| Max. Negotiated Rate |
$7,105.96 |
| Rate for Payer: Aetna of VT Commercial |
$7,105.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,535.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,535.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,357.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,283.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,983.97
|
| Rate for Payer: Cash Price |
$3,739.98
|
| Rate for Payer: Cigna Commercial |
$5,983.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,983.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,983.97
|
| Rate for Payer: Multiplan Commercial |
$6,956.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,357.97
|
| Rate for Payer: United Healthcare Commercial |
$7,105.96
|
|
|
TC99M Labeled RBC
|
Facility
|
OP
|
$7,479.96
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
343A956001
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,312.87 |
| Max. Negotiated Rate |
$7,105.96 |
| Rate for Payer: Aetna of VT Commercial |
$7,105.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6,701.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3,312.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6,701.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4,502.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6,357.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6,058.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3,365.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,946.57
|
| Rate for Payer: Cash Price |
$3,739.98
|
| Rate for Payer: Cigna Commercial |
$5,983.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,983.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,983.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$3,365.98
|
| Rate for Payer: Multiplan Commercial |
$6,956.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6,357.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3,365.98
|
| Rate for Payer: United Healthcare Commercial |
$7,105.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,365.98
|
| Rate for Payer: United Healthcare VA CCN |
$3,365.98
|
|
|
TC99M MAA
|
Facility
|
OP
|
$441.81
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
343A954001
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$195.68 |
| Max. Negotiated Rate |
$419.72 |
| Rate for Payer: Aetna of VT Commercial |
$419.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$195.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$265.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$375.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$357.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$198.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$351.24
|
| Rate for Payer: Cash Price |
$220.90
|
| Rate for Payer: Cigna Commercial |
$353.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$353.45
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$353.45
|
| Rate for Payer: Martins Point Health Care Commercial |
$198.81
|
| Rate for Payer: Multiplan Commercial |
$410.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$375.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$198.81
|
| Rate for Payer: United Healthcare Commercial |
$419.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$198.81
|
| Rate for Payer: United Healthcare VA CCN |
$198.81
|
|
|
TC99M MAA
|
Facility
|
IP
|
$441.81
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
343A954001
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$326.98 |
| Max. Negotiated Rate |
$419.72 |
| Rate for Payer: Aetna of VT Commercial |
$419.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$326.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$326.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$375.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$371.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$353.45
|
| Rate for Payer: Cash Price |
$220.90
|
| Rate for Payer: Cigna Commercial |
$353.45
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$353.45
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$353.45
|
| Rate for Payer: Multiplan Commercial |
$410.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$375.54
|
| Rate for Payer: United Healthcare Commercial |
$419.72
|
|
|
TC99M MAG3 (Mertiatide)
|
Facility
|
OP
|
$881.01
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
343A956201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$390.20 |
| Max. Negotiated Rate |
$836.96 |
| Rate for Payer: Aetna of VT Commercial |
$836.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$789.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$390.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$789.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$530.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$748.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$713.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$396.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$700.40
|
| Rate for Payer: Cash Price |
$440.50
|
| Rate for Payer: Cigna Commercial |
$704.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$396.45
|
| Rate for Payer: Multiplan Commercial |
$819.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$748.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$396.45
|
| Rate for Payer: United Healthcare Commercial |
$836.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$396.45
|
| Rate for Payer: United Healthcare VA CCN |
$396.45
|
|
|
TC99M MAG3 (Mertiatide)
|
Facility
|
IP
|
$881.01
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
343A956201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$652.04 |
| Max. Negotiated Rate |
$836.96 |
| Rate for Payer: Aetna of VT Commercial |
$836.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$652.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$652.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$748.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$740.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$704.81
|
| Rate for Payer: Cash Price |
$440.50
|
| Rate for Payer: Cigna Commercial |
$704.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$704.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$704.81
|
| Rate for Payer: Multiplan Commercial |
$819.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$748.86
|
| Rate for Payer: United Healthcare Commercial |
$836.96
|
|
|
TC99M Medronate up to 30 MCI
|
Facility
|
OP
|
$205.77
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
343A950301
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$195.48 |
| Rate for Payer: Aetna of VT Commercial |
$195.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$184.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$91.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$184.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$123.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$174.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$166.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$92.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$163.59
|
| Rate for Payer: Cash Price |
$102.89
|
| Rate for Payer: Cigna Commercial |
$164.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$164.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$164.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$92.60
|
| Rate for Payer: Multiplan Commercial |
$191.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$174.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$92.60
|
| Rate for Payer: United Healthcare Commercial |
$195.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$92.60
|
| Rate for Payer: United Healthcare VA CCN |
$92.60
|
|
