|
TETANUS/DIPTHERIA/PERTUSIS
|
Facility
|
OP
|
$254.33
|
|
|
Service Code
|
CPT 90715
|
| Hospital Charge Code |
6369071501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.44 |
| 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 |
$107.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$112.64
|
| 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 |
$153.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$206.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$114.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$202.19
|
| Rate for Payer: Cash Price |
$127.17
|
| 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: Martins Point Health Care Commercial |
$114.45
|
| Rate for Payer: Multiplan Commercial |
$236.53
|
| Rate for Payer: MVP Health Care of NY Commercial |
$216.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$114.45
|
| Rate for Payer: United Healthcare Commercial |
$241.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.45
|
| Rate for Payer: United Healthcare VA CCN |
$114.45
|
|
|
TETRACAINE 0.5% EYE DROPS
|
Professional
|
Both
|
$75.31
|
|
| Hospital Charge Code |
2500000288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.12 |
| Max. Negotiated Rate |
$70.79 |
| Rate for Payer: Aetna of VT Commercial |
$70.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.47
|
| Rate for Payer: Cash Price |
$37.66
|
| Rate for Payer: Multiplan Commercial |
$70.04
|
| Rate for Payer: United Healthcare Commercial |
$64.01
|
| Rate for Payer: United Healthcare VA CCN |
$30.12
|
|
|
TETRACAINE 0.5% EYE DROPS
|
Professional
|
Both
|
$75.31
|
|
|
Service Code
|
NDC 65074114
|
| Hospital Charge Code |
2500000288
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.12 |
| Max. Negotiated Rate |
$70.79 |
| Rate for Payer: Aetna of VT Commercial |
$70.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.47
|
| Rate for Payer: Cash Price |
$37.66
|
| Rate for Payer: Multiplan Commercial |
$70.04
|
| Rate for Payer: United Healthcare Commercial |
$64.01
|
| Rate for Payer: United Healthcare VA CCN |
$30.12
|
|
|
THC CONFIRM URINE
|
Facility
|
IP
|
$38.22
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
3008034902
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.29 |
| Max. Negotiated Rate |
$36.31 |
| Rate for Payer: Aetna of VT Commercial |
$36.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$28.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$28.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$32.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$32.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.58
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cigna Commercial |
$30.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$30.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$30.58
|
| Rate for Payer: Multiplan Commercial |
$35.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.49
|
| Rate for Payer: United Healthcare Commercial |
$36.31
|
|
|
THC CONFIRM URINE
|
Professional
|
Both
|
$38.22
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
3008034902
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.42 |
| Max. Negotiated Rate |
$127.04 |
| Rate for Payer: Aetna of VT Commercial |
$35.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cigna Commercial |
$29.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.42
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.42
|
| Rate for Payer: Martins Point Health Care Commercial |
$127.04
|
| Rate for Payer: Multiplan Commercial |
$35.54
|
| Rate for Payer: United Healthcare Commercial |
$32.49
|
| Rate for Payer: United Healthcare VA CCN |
$15.29
|
|
|
THC CONFIRM URINE
|
Facility
|
OP
|
$38.22
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
3008034902
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$124.32 |
| Rate for Payer: Aetna of VT Commercial |
$36.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$16.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$23.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$32.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.38
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cigna Commercial |
$30.58
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$30.58
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$30.58
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.20
|
| Rate for Payer: Multiplan Commercial |
$35.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$32.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.20
|
| Rate for Payer: United Healthcare Commercial |
$36.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.20
|
| Rate for Payer: United Healthcare VA CCN |
$17.20
|
|
|
THERAPEUTIC ACTIVITIES
|
Facility
|
OP
|
$164.66
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
4309753001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$156.43 |
| Rate for Payer: Aetna of VT Commercial |
$156.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$147.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$72.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$147.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$133.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$130.90
|
| Rate for Payer: Cash Price |
$82.33
|
| Rate for Payer: Cigna Commercial |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.10
|
| Rate for Payer: Multiplan Commercial |
$153.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$92.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$156.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.10
|
| Rate for Payer: United Healthcare VA CCN |
$74.10
|
|
|
THERAPEUTIC ACTIVITIES
|
Facility
|
IP
|
$164.66
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
4309753001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$121.86 |
| Max. Negotiated Rate |
$156.43 |
| Rate for Payer: Aetna of VT Commercial |
$156.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$121.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$121.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.73
|
| Rate for Payer: Cash Price |
$82.33
|
| Rate for Payer: Cigna Commercial |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.73
|
| Rate for Payer: Multiplan Commercial |
$153.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$139.96
|
| Rate for Payer: United Healthcare Commercial |
$156.43
|
|
|
THERAPEUTIC ACTIVITIES
|
Facility
|
OP
|
$164.66
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
4209753001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$156.43 |
| Rate for Payer: Aetna of VT Commercial |
$156.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$147.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$72.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$147.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$133.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$130.90
|
| Rate for Payer: Cash Price |
$82.33
|
| Rate for Payer: Cigna Commercial |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.73
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.10
|
| Rate for Payer: Multiplan Commercial |
$153.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$92.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$156.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.10
|
| Rate for Payer: United Healthcare VA CCN |
$74.10
|
|
|
THERAPEUTIC ACTIVITIES
|
Facility
|
IP
|
$164.66
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
4209753001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$121.86 |
| Max. Negotiated Rate |
$156.43 |
| Rate for Payer: Aetna of VT Commercial |
$156.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$121.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$121.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.73
|
| Rate for Payer: Cash Price |
$82.33
|
| Rate for Payer: Cigna Commercial |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.73
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.73
|
| Rate for Payer: Multiplan Commercial |
$153.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$139.96
|
| Rate for Payer: United Healthcare Commercial |
$156.43
|
|
|
THERAPEUTIC EXERCISES
|
Professional
|
Both
|
$33.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
9839711001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$45.78 |
| Rate for Payer: Aetna of VT Commercial |
$31.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$39.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$34.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$32.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$34.30
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$34.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$45.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$45.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$28.54
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$40.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$28.54
|
| Rate for Payer: United Healthcare Commercial |
$43.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.54
|
| Rate for Payer: United Healthcare VA CCN |
$28.54
|
|
|
THERAPEUTIC EXERCISES
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
9839711001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna of VT Commercial |
$31.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$24.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$24.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.40
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.05
|
| Rate for Payer: United Healthcare Commercial |
$31.35
|
|
|
THERAPEUTIC EXERCISES
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
9839711001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna of VT Commercial |
$31.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$28.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.23
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$26.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$26.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.85
|
| Rate for Payer: Multiplan Commercial |
$30.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$28.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.85
|
| Rate for Payer: United Healthcare Commercial |
$31.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.85
|
| Rate for Payer: United Healthcare VA CCN |
$14.85
|
|
|
THERAPEUTIC EXERCISES EA 15MIN
|
Facility
|
IP
|
$132.68
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
4309711001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$98.20 |
| Max. Negotiated Rate |
$126.05 |
| Rate for Payer: Aetna of VT Commercial |
$126.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.14
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.14
|
| Rate for Payer: Multiplan Commercial |
$123.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.78
|
| Rate for Payer: United Healthcare Commercial |
$126.05
|
|
|
THERAPEUTIC EXERCISES EA 15MIN
|
Facility
|
IP
|
$132.68
|
|
|
Service Code
|
CPT 97110 GP
|
| Hospital Charge Code |
4209711001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$98.20 |
| Max. Negotiated Rate |
$126.05 |
| Rate for Payer: Aetna of VT Commercial |
$126.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.14
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.14
|
| Rate for Payer: Multiplan Commercial |
$123.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.78
|
| Rate for Payer: United Healthcare Commercial |
$126.05
|
|
|
THERAPEUTIC EXERCISES EA 15MIN
|
Facility
|
OP
|
$132.68
|
|
|
Service Code
|
CPT 97110 GP
|
| Hospital Charge Code |
4209711001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$58.76 |
| Max. Negotiated Rate |
$126.05 |
| Rate for Payer: Aetna of VT Commercial |
$126.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.48
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$59.71
|
| Rate for Payer: Multiplan Commercial |
$123.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$59.71
|
| Rate for Payer: United Healthcare Commercial |
$126.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.71
|
| Rate for Payer: United Healthcare VA CCN |
$59.71
|
|
|
THERAPEUTIC EXERCISES EA 15MIN
|
Facility
|
OP
|
$132.68
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
4309711001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$58.76 |
| Max. Negotiated Rate |
$126.05 |
| Rate for Payer: Aetna of VT Commercial |
$126.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.48
|
| Rate for Payer: Cash Price |
$66.34
|
| Rate for Payer: Cigna Commercial |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$106.14
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$106.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$59.71
|
| Rate for Payer: Multiplan Commercial |
$123.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$74.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$59.71
|
| Rate for Payer: United Healthcare Commercial |
$126.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.71
|
| Rate for Payer: United Healthcare VA CCN |
$59.71
|
|
|
THER/DIAG CONCURRENT INF
|
Facility
|
IP
|
$316.40
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
4509636801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$234.17 |
| Max. Negotiated Rate |
$300.58 |
| Rate for Payer: Aetna of VT Commercial |
$300.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$234.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$234.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$265.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$253.12
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cigna Commercial |
$253.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$253.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$253.12
|
| Rate for Payer: Multiplan Commercial |
$294.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.94
|
| Rate for Payer: United Healthcare Commercial |
$300.58
|
|
|
THER/DIAG CONCURRENT INF
|
Facility
|
OP
|
$316.40
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
4509636801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$140.13 |
| Max. Negotiated Rate |
$300.58 |
| Rate for Payer: Aetna of VT Commercial |
$300.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$283.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$140.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$283.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$190.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$268.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$256.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$142.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$251.54
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cigna Commercial |
$253.12
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$253.12
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$253.12
|
| Rate for Payer: Martins Point Health Care Commercial |
$142.38
|
| Rate for Payer: Multiplan Commercial |
$294.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$268.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$142.38
|
| Rate for Payer: United Healthcare Commercial |
$300.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.38
|
| Rate for Payer: United Healthcare VA CCN |
$142.38
|
|
|
THER IVNTJ 1ST 15 MIN
|
Facility
|
IP
|
$119.12
|
|
|
Service Code
|
CPT 97129 GO
|
| Hospital Charge Code |
4309712901
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna of VT Commercial |
$113.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.30
|
| Rate for Payer: Cash Price |
$59.56
|
| Rate for Payer: Cigna Commercial |
$95.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.30
|
| Rate for Payer: Multiplan Commercial |
$110.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$113.16
|
|
|
THER IVNTJ 1ST 15 MIN
|
Facility
|
OP
|
$119.12
|
|
|
Service Code
|
CPT 97129 GO
|
| Hospital Charge Code |
4309712901
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$52.76 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna of VT Commercial |
$113.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$71.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.70
|
| Rate for Payer: Cash Price |
$59.56
|
| Rate for Payer: Cigna Commercial |
$95.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.60
|
| Rate for Payer: Multiplan Commercial |
$110.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.71
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.60
|
| Rate for Payer: United Healthcare Commercial |
$113.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.60
|
| Rate for Payer: United Healthcare VA CCN |
$53.60
|
|
|
THER IVNTJ EA ADDL 15 MIN
|
Facility
|
OP
|
$99.26
|
|
|
Service Code
|
CPT 97130 GO
|
| Hospital Charge Code |
4309713001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$43.96 |
| Max. Negotiated Rate |
$94.30 |
| Rate for Payer: Aetna of VT Commercial |
$94.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$59.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$78.91
|
| Rate for Payer: Cash Price |
$49.63
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.41
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.41
|
| Rate for Payer: Martins Point Health Care Commercial |
$44.67
|
| Rate for Payer: Multiplan Commercial |
$92.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$44.67
|
| Rate for Payer: United Healthcare Commercial |
$94.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.67
|
| Rate for Payer: United Healthcare VA CCN |
$44.67
|
|
|
THER IVNTJ EA ADDL 15 MIN
|
Facility
|
IP
|
$99.26
|
|
|
Service Code
|
CPT 97130 GO
|
| Hospital Charge Code |
4309713001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$73.46 |
| Max. Negotiated Rate |
$94.30 |
| Rate for Payer: Aetna of VT Commercial |
$94.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$73.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$73.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$79.41
|
| Rate for Payer: Cash Price |
$49.63
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$79.41
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$92.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$84.37
|
| Rate for Payer: United Healthcare Commercial |
$94.30
|
|
|
THER/PRO/DX INJ PUSH EA NEW DG
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 96376
|
| Hospital Charge Code |
9819637602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$83.71 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Aetna of VT Commercial |
$179.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$169.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$83.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$169.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$113.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$160.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$153.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$85.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$150.25
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$151.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$151.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$151.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$175.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$160.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$85.05
|
| Rate for Payer: United Healthcare Commercial |
$179.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.05
|
| Rate for Payer: United Healthcare VA CCN |
$85.05
|
|
|
THER/PRO/DX INJ PUSH EA NEW DG
|
Professional
|
Both
|
$189.00
|
|
|
Service Code
|
CPT 96376
|
| Hospital Charge Code |
9819637602
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$10.95 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna of VT Commercial |
$177.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$169.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$169.33
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$10.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$14.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$14.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.00
|
| Rate for Payer: Multiplan Commercial |
$175.77
|
| Rate for Payer: United Healthcare Commercial |
$160.65
|
| Rate for Payer: United Healthcare VA CCN |
$19.10
|
|
