|
THROMBOLYSIS CEREBRAL IV INFUS
|
Facility
|
IP
|
$1,495.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
9813719501
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,106.45 |
| Max. Negotiated Rate |
$1,420.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,420.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,106.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,106.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,270.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,255.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,196.00
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cigna Commercial |
$1,196.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,196.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,196.00
|
| Rate for Payer: Multiplan Commercial |
$1,390.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.75
|
| Rate for Payer: United Healthcare Commercial |
$1,420.25
|
|
|
THROMBOLYSIS CEREBRAL IV INFUS
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
9813719502
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$363.86 |
| Max. Negotiated Rate |
$1,405.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,405.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,339.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,339.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$560.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$560.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$560.92
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cigna Commercial |
$1,385.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,224.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,224.04
|
| Rate for Payer: Multiplan Commercial |
$1,390.35
|
| Rate for Payer: United Healthcare Commercial |
$1,270.75
|
| Rate for Payer: United Healthcare VA CCN |
$363.86
|
|
|
THROMBOLYSIS CEREBRAL IV INFUS
|
Facility
|
OP
|
$498.39
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
4503719501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$220.74 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$220.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$446.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$300.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$403.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$224.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$396.22
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$224.28
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$224.28
|
| Rate for Payer: United Healthcare VA CCN |
$224.28
|
|
|
THROMBOLYSIS CEREBRAL IV INFUS
|
Facility
|
IP
|
$498.39
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
4503719501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$368.86 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna of VT Commercial |
$473.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$368.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$423.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$418.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$398.71
|
| Rate for Payer: Cash Price |
$249.20
|
| Rate for Payer: Cigna Commercial |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$398.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$398.71
|
| Rate for Payer: Multiplan Commercial |
$463.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$423.63
|
| Rate for Payer: United Healthcare Commercial |
$473.47
|
|
|
THROMBOLYSIS CEREBRAL IV INFUS
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
9813719501
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$363.86 |
| Max. Negotiated Rate |
$1,405.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,405.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,339.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,339.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$560.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$560.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$560.92
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cigna Commercial |
$1,385.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,224.04
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,224.04
|
| Rate for Payer: Multiplan Commercial |
$1,390.35
|
| Rate for Payer: United Healthcare Commercial |
$1,270.75
|
| Rate for Payer: United Healthcare VA CCN |
$363.86
|
|
|
THROMBOLYSIS CEREBRAL IV INFUS
|
Facility
|
IP
|
$1,495.00
|
|
|
Service Code
|
CPT 37195
|
| Hospital Charge Code |
9813719502
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1,106.45 |
| Max. Negotiated Rate |
$1,420.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,420.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,106.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,106.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,270.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,255.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,196.00
|
| Rate for Payer: Cash Price |
$747.50
|
| Rate for Payer: Cigna Commercial |
$1,196.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,196.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,196.00
|
| Rate for Payer: Multiplan Commercial |
$1,390.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,270.75
|
| Rate for Payer: United Healthcare Commercial |
$1,420.25
|
|
|
THROMBOPLASTIN TIME PARTIAL
|
Professional
|
Both
|
$107.79
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$101.32 |
| Rate for Payer: Aetna of VT Commercial |
$101.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$11.05
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cigna Commercial |
$7.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.38
|
| Rate for Payer: Multiplan Commercial |
$100.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare Commercial |
$9.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare VA CCN |
$6.47
|
|
|
THROMBOPLASTIN TIME PARTIAL
|
Facility
|
IP
|
$107.79
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.78 |
| Max. Negotiated Rate |
$102.40 |
| Rate for Payer: Aetna of VT Commercial |
$102.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$90.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$86.23
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cigna Commercial |
$86.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$86.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$86.23
|
| Rate for Payer: Multiplan Commercial |
$100.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$91.62
|
| Rate for Payer: United Healthcare Commercial |
$102.40
|
|
|
THROMBOPLASTIN TIME PARTIAL
|
Facility
|
OP
|
$89.96
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
3008573001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$85.46 |
| Rate for Payer: Aetna of VT Commercial |
$85.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$29.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$29.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$54.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$76.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.87
|
| 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 |
$71.52
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Cigna Commercial |
$71.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$83.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$76.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.48
|
| Rate for Payer: United Healthcare Commercial |
$85.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.01
|
| Rate for Payer: United Healthcare VA CCN |
$40.48
|
|
|
THROMBOPLASTIN TIME PARTIAL
|
Facility
|
IP
|
$89.96
|
|
|
Service Code
|
CPT 85730
|
| Hospital Charge Code |
3008573001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.58 |
| Max. Negotiated Rate |
$85.46 |
| Rate for Payer: Aetna of VT Commercial |
$85.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$66.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$66.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$76.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$75.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$71.97
|
| Rate for Payer: Cash Price |
$44.98
|
| Rate for Payer: Cigna Commercial |
$71.97
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.97
|
| Rate for Payer: Multiplan Commercial |
$83.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$76.47
|
| Rate for Payer: United Healthcare Commercial |
$85.46
|
|
|
THROMBOPLASTIN TIME PARTIAL
|
Facility
|
OP
|
$107.79
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$102.40 |
| Rate for Payer: Aetna of VT Commercial |
$102.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$47.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$64.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$87.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$48.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$85.69
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cigna Commercial |
$86.23
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$86.23
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$86.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$48.51
|
| Rate for Payer: Multiplan Commercial |
$100.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$91.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$48.51
|
| Rate for Payer: United Healthcare Commercial |
$102.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare VA CCN |
$48.51
|
|
|
THROMBOPLASTIN TIME PARTIAL X2
|
Facility
|
IP
|
$215.59
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.56 |
| Max. Negotiated Rate |
$204.81 |
| Rate for Payer: Aetna of VT Commercial |
$204.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$159.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$159.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$183.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$181.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$172.47
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: Cigna Commercial |
$172.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$172.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$172.47
|
| Rate for Payer: Multiplan Commercial |
$200.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$183.25
|
| Rate for Payer: United Healthcare Commercial |
$204.81
|
|
|
THROMBOPLASTIN TIME PARTIAL X2
|
Professional
|
Both
|
$215.59
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$202.65 |
| Rate for Payer: Aetna of VT Commercial |
$202.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$11.05
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: Cigna Commercial |
$7.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$6.38
|
| Rate for Payer: Multiplan Commercial |
$200.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare Commercial |
$9.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare VA CCN |
$6.47
|
|
|
THROMBOPLASTIN TIME PARTIAL X2
|
Facility
|
OP
|
$215.59
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
3008573202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$204.81 |
| Rate for Payer: Aetna of VT Commercial |
$204.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$95.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$31.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$129.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$183.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$174.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$97.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$171.39
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: Cigna Commercial |
$172.47
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$172.47
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$172.47
|
| Rate for Payer: Martins Point Health Care Commercial |
$97.02
|
| Rate for Payer: Multiplan Commercial |
$200.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$183.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$97.02
|
| Rate for Payer: United Healthcare Commercial |
$204.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare VA CCN |
$97.02
|
|
|
THYROGLOBULIN ANTIBODY
|
Facility
|
OP
|
$199.81
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
3008680001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$189.82 |
| Rate for Payer: Aetna of VT Commercial |
$189.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$88.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$120.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$169.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$161.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$89.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$158.85
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$159.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$159.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$159.85
|
| Rate for Payer: Martins Point Health Care Commercial |
$89.91
|
| Rate for Payer: Multiplan Commercial |
$185.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$169.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$89.91
|
| Rate for Payer: United Healthcare Commercial |
$189.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare VA CCN |
$89.91
|
|
|
THYROGLOBULIN ANTIBODY
|
Facility
|
IP
|
$199.81
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
3008680001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.88 |
| Max. Negotiated Rate |
$189.82 |
| Rate for Payer: Aetna of VT Commercial |
$189.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$147.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$147.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$169.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$167.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$159.85
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$159.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$159.85
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$159.85
|
| Rate for Payer: Multiplan Commercial |
$185.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$169.84
|
| Rate for Payer: United Healthcare Commercial |
$189.82
|
|
|
THYROGLOBULIN ANTIBODY
|
Professional
|
Both
|
$199.81
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
3008680001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.69 |
| Max. Negotiated Rate |
$187.82 |
| Rate for Payer: Aetna of VT Commercial |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$16.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$27.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$27.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$18.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$27.19
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$19.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$15.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$15.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$15.69
|
| Rate for Payer: Multiplan Commercial |
$185.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$15.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare Commercial |
$24.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare VA CCN |
$15.91
|
|
|
TIB COMPONENT CEMENTED T3I4R
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780047361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,505.86 |
| Max. Negotiated Rate |
$3,230.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,230.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,046.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,046.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,046.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,890.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,754.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,530.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,703.00
|
| Rate for Payer: Cash Price |
$1,700.00
|
| Rate for Payer: Cigna Commercial |
$2,720.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,720.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,720.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,530.00
|
| Rate for Payer: Multiplan Commercial |
$3,162.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,890.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,530.00
|
| Rate for Payer: United Healthcare Commercial |
$3,230.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,530.00
|
| Rate for Payer: United Healthcare VA CCN |
$1,530.00
|
|
|
TIB COMPONENT CEMENTED T3I4R
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2780047361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,516.34 |
| Max. Negotiated Rate |
$3,230.00 |
| Rate for Payer: Aetna of VT Commercial |
$3,230.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,516.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,516.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,890.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,856.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,720.00
|
| Rate for Payer: Cash Price |
$1,700.00
|
| Rate for Payer: Cigna Commercial |
$2,720.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,720.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,720.00
|
| Rate for Payer: Multiplan Commercial |
$3,162.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,890.00
|
| Rate for Payer: United Healthcare Commercial |
$3,230.00
|
|
|
TIBCUTBL-CT-GMK-RM-#3
|
Facility
|
OP
|
$147.50
|
|
| Hospital Charge Code |
2720073891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.33 |
| Max. Negotiated Rate |
$140.12 |
| Rate for Payer: Aetna of VT Commercial |
$140.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$132.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$65.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$132.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$88.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$125.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$119.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$66.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$117.26
|
| Rate for Payer: Cash Price |
$73.75
|
| Rate for Payer: Cigna Commercial |
$118.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$118.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$118.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$137.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$125.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$66.38
|
| Rate for Payer: United Healthcare Commercial |
$140.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66.38
|
| Rate for Payer: United Healthcare VA CCN |
$66.38
|
|
|
TIBCUTBL-CT-GMK-RM-#3
|
Facility
|
IP
|
$147.50
|
|
| Hospital Charge Code |
2720073891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.16 |
| Max. Negotiated Rate |
$140.12 |
| Rate for Payer: Aetna of VT Commercial |
$140.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$109.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$109.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$125.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$123.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$118.00
|
| Rate for Payer: Cash Price |
$73.75
|
| Rate for Payer: Cigna Commercial |
$118.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$118.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$118.00
|
| Rate for Payer: Multiplan Commercial |
$137.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$125.38
|
| Rate for Payer: United Healthcare Commercial |
$140.12
|
|
|
TIBIA BONE MODEL LEFT MEDIAL
|
Facility
|
OP
|
$103.40
|
|
| Hospital Charge Code |
2720051971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.80 |
| Max. Negotiated Rate |
$98.23 |
| Rate for Payer: Aetna of VT Commercial |
$98.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$45.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$62.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$83.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$46.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$82.20
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cigna Commercial |
$82.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$82.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$82.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$46.53
|
| Rate for Payer: Multiplan Commercial |
$96.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$46.53
|
| Rate for Payer: United Healthcare Commercial |
$98.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.53
|
| Rate for Payer: United Healthcare VA CCN |
$46.53
|
|
|
TIBIA BONE MODEL LEFT MEDIAL
|
Facility
|
IP
|
$103.40
|
|
| Hospital Charge Code |
2720051971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.53 |
| Max. Negotiated Rate |
$98.23 |
| Rate for Payer: Aetna of VT Commercial |
$98.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$76.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$76.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$82.72
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cigna Commercial |
$82.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$82.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$82.72
|
| Rate for Payer: Multiplan Commercial |
$96.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.89
|
| Rate for Payer: United Healthcare Commercial |
$98.23
|
|
|
TIBIAL ARTHROSCOPY/SURGERY
|
Facility
|
IP
|
$2,813.00
|
|
|
Service Code
|
CPT 29855
|
| Hospital Charge Code |
9822985501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$2,081.90 |
| Max. Negotiated Rate |
$2,672.35 |
| Rate for Payer: Aetna of VT Commercial |
$2,672.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,081.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,081.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,391.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,362.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,250.40
|
| Rate for Payer: Cash Price |
$1,406.50
|
| Rate for Payer: Cigna Commercial |
$2,250.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,250.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,250.40
|
| Rate for Payer: Multiplan Commercial |
$2,616.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,391.05
|
| Rate for Payer: United Healthcare Commercial |
$2,672.35
|
|
|
TIBIAL ARTHROSCOPY/SURGERY
|
Facility
|
OP
|
$2,961.00
|
|
|
Service Code
|
CPT 29856
|
| Hospital Charge Code |
9822985601
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,311.43 |
| Max. Negotiated Rate |
$2,812.95 |
| Rate for Payer: Aetna of VT Commercial |
$2,812.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,652.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,311.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,652.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,782.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,516.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,398.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,332.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,353.99
|
| Rate for Payer: Cash Price |
$1,480.50
|
| Rate for Payer: Cigna Commercial |
$2,368.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,368.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,368.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,332.45
|
| Rate for Payer: Multiplan Commercial |
$2,753.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,516.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,332.45
|
| Rate for Payer: United Healthcare Commercial |
$2,812.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,332.45
|
| Rate for Payer: United Healthcare VA CCN |
$1,332.45
|
|
