|
TENDON SHEATH INCISION
|
Facility
|
OP
|
$1,861.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
5102605501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$824.24 |
| Max. Negotiated Rate |
$1,767.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,767.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,667.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$824.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,667.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,120.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,581.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,507.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$837.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,479.49
|
| Rate for Payer: Cash Price |
$930.50
|
| Rate for Payer: Cigna Commercial |
$1,488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,488.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$837.45
|
| Rate for Payer: Multiplan Commercial |
$1,730.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,581.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$837.45
|
| Rate for Payer: United Healthcare Commercial |
$1,767.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$837.45
|
| Rate for Payer: United Healthcare VA CCN |
$837.45
|
|
|
TENDON SHEATH INCISION
|
Professional
|
Both
|
$1,861.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
5102605501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$283.78 |
| Max. Negotiated Rate |
$1,749.34 |
| Rate for Payer: Aetna of VT Commercial |
$1,749.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,667.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$292.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,667.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$397.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$986.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$986.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$326.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$986.14
|
| Rate for Payer: Cash Price |
$930.50
|
| Rate for Payer: Cash Price |
$930.50
|
| Rate for Payer: Cigna Commercial |
$535.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$905.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$905.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$557.12
|
| Rate for Payer: Multiplan Commercial |
$1,730.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$283.78
|
| Rate for Payer: United Healthcare Commercial |
$436.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.78
|
| Rate for Payer: United Healthcare VA CCN |
$283.78
|
|
|
TENDON SHEATH INCISION
|
Facility
|
OP
|
$3,393.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
9602605501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,502.76 |
| Max. Negotiated Rate |
$3,223.35 |
| Rate for Payer: Aetna of VT Commercial |
$3,223.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,039.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,502.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,039.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,042.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,884.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,748.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,526.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,697.43
|
| Rate for Payer: Cash Price |
$1,696.50
|
| Rate for Payer: Cigna Commercial |
$2,714.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,714.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,714.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,526.85
|
| Rate for Payer: Multiplan Commercial |
$3,155.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,884.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,526.85
|
| Rate for Payer: United Healthcare Commercial |
$3,223.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,526.85
|
| Rate for Payer: United Healthcare VA CCN |
$1,526.85
|
|
|
TENDON SHEATH INCISION
|
Professional
|
Both
|
$3,393.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
9602605501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$283.78 |
| Max. Negotiated Rate |
$3,189.42 |
| Rate for Payer: Aetna of VT Commercial |
$3,189.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,039.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$292.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,039.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$397.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$986.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$986.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$326.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$986.14
|
| Rate for Payer: Cash Price |
$1,696.50
|
| Rate for Payer: Cash Price |
$1,696.50
|
| Rate for Payer: Cigna Commercial |
$535.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$905.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$905.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$557.12
|
| Rate for Payer: Multiplan Commercial |
$3,155.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$283.78
|
| Rate for Payer: United Healthcare Commercial |
$436.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.78
|
| Rate for Payer: United Healthcare VA CCN |
$283.78
|
|
|
TENDON SHEATH INCISION
|
Facility
|
IP
|
$1,861.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
5102605501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,377.33 |
| Max. Negotiated Rate |
$1,767.95 |
| Rate for Payer: Aetna of VT Commercial |
$1,767.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,377.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,377.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,581.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,563.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,488.80
|
| Rate for Payer: Cash Price |
$930.50
|
| Rate for Payer: Cigna Commercial |
$1,488.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,488.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,488.80
|
| Rate for Payer: Multiplan Commercial |
$1,730.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,581.85
|
| Rate for Payer: United Healthcare Commercial |
$1,767.95
|
|
|
TENDON SHEATH INCISION
|
Facility
|
IP
|
$3,393.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
9602605501
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$2,511.16 |
| Max. Negotiated Rate |
$3,223.35 |
| Rate for Payer: Aetna of VT Commercial |
$3,223.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,511.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,511.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,884.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,850.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,714.40
|
| Rate for Payer: Cash Price |
$1,696.50
|
| Rate for Payer: Cigna Commercial |
$2,714.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,714.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,714.40
|
| Rate for Payer: Multiplan Commercial |
$3,155.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,884.05
|
| Rate for Payer: United Healthcare Commercial |
$3,223.35
|
|
|
TENDON SHEATH INCISION
|
Facility
|
IP
|
$1,533.00
|
|
|
Service Code
|
CPT 26055
|
| Hospital Charge Code |
9602605502
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,134.57 |
| Max. Negotiated Rate |
$1,456.35 |
| Rate for Payer: Aetna of VT Commercial |
$1,456.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,134.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,134.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,303.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,287.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,226.40
|
| Rate for Payer: Cash Price |
$766.50
|
| Rate for Payer: Cigna Commercial |
$1,226.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,226.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,226.40
|
| Rate for Payer: Multiplan Commercial |
$1,425.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,303.05
|
| Rate for Payer: United Healthcare Commercial |
$1,456.35
|
|
|
TENODESIS LONG TENDON BICEPS
|
Facility
|
IP
|
$1,790.00
|
|
|
Service Code
|
CPT 23430
|
| Hospital Charge Code |
9822343001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,324.78 |
| Max. Negotiated Rate |
$1,700.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,700.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,324.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,324.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,521.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,503.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,432.00
|
| Rate for Payer: Cash Price |
$895.00
|
| Rate for Payer: Cigna Commercial |
$1,432.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,432.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,432.00
|
| Rate for Payer: Multiplan Commercial |
$1,664.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,521.50
|
| Rate for Payer: United Healthcare Commercial |
$1,700.50
|
|
|
TENODESIS LONG TENDON BICEPS
|
Facility
|
OP
|
$1,790.00
|
|
|
Service Code
|
CPT 23430
|
| Hospital Charge Code |
9822343001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$792.79 |
| Max. Negotiated Rate |
$1,700.50 |
| Rate for Payer: Aetna of VT Commercial |
$1,700.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$792.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,077.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,521.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,449.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$805.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,423.05
|
| Rate for Payer: Cash Price |
$895.00
|
| Rate for Payer: Cigna Commercial |
$1,432.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,432.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,432.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$805.50
|
| Rate for Payer: Multiplan Commercial |
$1,664.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,521.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$805.50
|
| Rate for Payer: United Healthcare Commercial |
$1,700.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$805.50
|
| Rate for Payer: United Healthcare VA CCN |
$805.50
|
|
|
TENODESIS LONG TENDON BICEPS
|
Professional
|
Both
|
$1,790.00
|
|
|
Service Code
|
CPT 23430
|
| Hospital Charge Code |
9822343001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$703.90 |
| Max. Negotiated Rate |
$1,682.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,682.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$725.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,603.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$985.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,205.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,205.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$809.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,205.47
|
| Rate for Payer: Cash Price |
$895.00
|
| Rate for Payer: Cash Price |
$895.00
|
| Rate for Payer: Cigna Commercial |
$1,334.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,172.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,172.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$703.90
|
| Rate for Payer: Multiplan Commercial |
$1,664.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$999.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$703.90
|
| Rate for Payer: United Healthcare Commercial |
$1,082.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$703.90
|
| Rate for Payer: United Healthcare VA CCN |
$703.90
|
|
|
TEST FOR ACETONE/KETONES
|
Facility
|
OP
|
$71.35
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
3008200901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$67.78 |
| Rate for Payer: Aetna of VT Commercial |
$67.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$31.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$42.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$60.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$57.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$32.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$56.72
|
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Cigna Commercial |
$57.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$57.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$57.08
|
| Rate for Payer: Martins Point Health Care Commercial |
$32.11
|
| Rate for Payer: Multiplan Commercial |
$66.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$32.11
|
| Rate for Payer: United Healthcare Commercial |
$67.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.52
|
| Rate for Payer: United Healthcare VA CCN |
$32.11
|
|
|
TEST FOR ACETONE/KETONES
|
Facility
|
IP
|
$71.35
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
3008200901
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$67.78 |
| Rate for Payer: Aetna of VT Commercial |
$67.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$52.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$52.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$60.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$57.08
|
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Cigna Commercial |
$57.08
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$57.08
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$57.08
|
| Rate for Payer: Multiplan Commercial |
$66.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.65
|
| Rate for Payer: United Healthcare Commercial |
$67.78
|
|
|
TESTOSTERONE CYPIONAT 200MG/ML
|
Professional
|
Both
|
$47.81
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636J107101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$44.94 |
| Rate for Payer: Aetna of VT Commercial |
$44.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.03
|
| Rate for Payer: Cash Price |
$23.91
|
| Rate for Payer: Cash Price |
$23.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.03
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.03
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$44.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.03
|
| Rate for Payer: United Healthcare VA CCN |
$0.03
|
|
|
TESTOSTERONE CYPIONAT 200MG/ML
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636J107101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.08
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Professional
|
Both
|
$267.94
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.96 |
| Max. Negotiated Rate |
$251.86 |
| Rate for Payer: Aetna of VT Commercial |
$251.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$45.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$45.16
|
| Rate for Payer: Cash Price |
$133.97
|
| Rate for Payer: Cash Price |
$133.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.96
|
| Rate for Payer: Multiplan Commercial |
$249.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.37
|
| Rate for Payer: United Healthcare Commercial |
$57.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.37
|
| Rate for Payer: United Healthcare VA CCN |
$37.37
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Facility
|
OP
|
$86.16
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna of VT Commercial |
$81.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$69.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.50
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna Commercial |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.77
|
| Rate for Payer: Multiplan Commercial |
$80.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare Commercial |
$81.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare VA CCN |
$38.77
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Facility
|
IP
|
$86.16
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.77 |
| Max. Negotiated Rate |
$81.85 |
| Rate for Payer: Aetna of VT Commercial |
$81.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$63.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$63.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.93
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna Commercial |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.93
|
| Rate for Payer: Multiplan Commercial |
$80.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.24
|
| Rate for Payer: United Healthcare Commercial |
$81.85
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Professional
|
Both
|
$267.94
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.96 |
| Max. Negotiated Rate |
$251.86 |
| Rate for Payer: Aetna of VT Commercial |
$251.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$45.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$45.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$45.16
|
| Rate for Payer: Cash Price |
$133.97
|
| Rate for Payer: Cash Price |
$133.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$46.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$46.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.96
|
| Rate for Payer: Multiplan Commercial |
$249.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.37
|
| Rate for Payer: United Healthcare Commercial |
$57.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.37
|
| Rate for Payer: United Healthcare VA CCN |
$37.37
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Facility
|
IP
|
$86.16
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.77 |
| Max. Negotiated Rate |
$81.85 |
| Rate for Payer: Aetna of VT Commercial |
$81.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$63.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$63.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.93
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna Commercial |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.93
|
| Rate for Payer: Multiplan Commercial |
$80.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.24
|
| Rate for Payer: United Healthcare Commercial |
$81.85
|
|
|
TETANUS-DIPHTHERIA TOXOIDS/PF
|
Facility
|
OP
|
$86.16
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
6369071401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna of VT Commercial |
$81.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$93.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$51.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$69.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$68.50
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna Commercial |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$68.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$68.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.77
|
| Rate for Payer: Multiplan Commercial |
$80.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare Commercial |
$81.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.77
|
| Rate for Payer: United Healthcare VA CCN |
$38.77
|
|
|
TETANUS/DIPTHERIA/PERTUSIS
|
Professional
|
Both
|
$254.33
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.07 |
| Max. Negotiated Rate |
$239.07 |
| Rate for Payer: Aetna of VT Commercial |
$239.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$55.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$45.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.60
|
| Rate for Payer: Cash Price |
$127.17
|
| Rate for Payer: Cash Price |
$127.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$39.07
|
| Rate for Payer: Multiplan Commercial |
$236.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$39.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$39.81
|
| Rate for Payer: United Healthcare Commercial |
$61.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.81
|
| Rate for Payer: United Healthcare VA CCN |
$39.81
|
|
|
TETANUS/DIPTHERIA/PERTUSIS
|
Facility
|
IP
|
$254.33
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.23 |
| Max. Negotiated Rate |
$241.61 |
| Rate for Payer: Aetna of VT Commercial |
$241.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$188.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$188.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$213.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$203.46
|
| Rate for Payer: Cash Price |
$127.17
|
| Rate for Payer: Cigna Commercial |
$203.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$203.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$203.46
|
| Rate for Payer: Multiplan Commercial |
$236.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$216.18
|
| Rate for Payer: United Healthcare Commercial |
$241.61
|
|
|
TETANUS/DIPTHERIA/PERTUSIS
|
Facility
|
OP
|
$316.10
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.44 |
| Max. Negotiated Rate |
$300.30 |
| Rate for Payer: Aetna of VT Commercial |
$300.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$140.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$190.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$256.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$251.30
|
| Rate for Payer: Cash Price |
$158.05
|
| Rate for Payer: Cash Price |
$158.05
|
| Rate for Payer: Cigna Commercial |
$252.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.25
|
| Rate for Payer: Multiplan Commercial |
$293.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.25
|
| Rate for Payer: United Healthcare Commercial |
$300.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.25
|
| Rate for Payer: United Healthcare VA CCN |
$142.25
|
|
|
TETANUS/DIPTHERIA/PERTUSIS
|
Professional
|
Both
|
$316.10
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.07 |
| Max. Negotiated Rate |
$297.13 |
| Rate for Payer: Aetna of VT Commercial |
$297.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$55.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$45.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$50.60
|
| Rate for Payer: Cash Price |
$158.05
|
| Rate for Payer: Cash Price |
$158.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$39.07
|
| Rate for Payer: Multiplan Commercial |
$293.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$39.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$39.81
|
| Rate for Payer: United Healthcare Commercial |
$61.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.81
|
| Rate for Payer: United Healthcare VA CCN |
$39.81
|
|
|
TETANUS/DIPTHERIA/PERTUSIS
|
Facility
|
IP
|
$316.10
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.95 |
| Max. Negotiated Rate |
$300.30 |
| Rate for Payer: Aetna of VT Commercial |
$300.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$233.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$233.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$252.88
|
| Rate for Payer: Cash Price |
$158.05
|
| Rate for Payer: Cigna Commercial |
$252.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.88
|
| Rate for Payer: Multiplan Commercial |
$293.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.69
|
| Rate for Payer: United Healthcare Commercial |
$300.30
|
|
