|
ACL BACKUP SYS SWIVELOCK 4.75
|
Facility
|
IP
|
$1,250.11
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780072091
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$925.21 |
| Max. Negotiated Rate |
$1,187.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,187.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$925.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$925.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,062.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,050.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,000.09
|
| Rate for Payer: Cash Price |
$625.06
|
| Rate for Payer: Cigna Commercial |
$1,000.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,000.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,000.09
|
| Rate for Payer: Multiplan Commercial |
$1,162.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,062.59
|
| Rate for Payer: United Healthcare Commercial |
$1,187.60
|
|
|
ACL BACKUP SYS SWIVELOCK 4.75
|
Facility
|
OP
|
$1,250.11
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2780072091
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$553.67 |
| Max. Negotiated Rate |
$1,187.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,187.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,119.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$553.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,119.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$752.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,062.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,012.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$562.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$993.84
|
| Rate for Payer: Cash Price |
$625.06
|
| Rate for Payer: Cigna Commercial |
$1,000.09
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,000.09
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,000.09
|
| Rate for Payer: Martins Point Health Care Commercial |
$562.55
|
| Rate for Payer: Multiplan Commercial |
$1,162.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,062.59
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$562.55
|
| Rate for Payer: United Healthcare Commercial |
$1,187.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$562.55
|
| Rate for Payer: United Healthcare VA CCN |
$562.55
|
|
|
ACNE SURGERY
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$205.01 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Aetna of VT Commercial |
$263.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$205.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$205.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$235.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$232.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$221.60
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$221.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$221.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$221.60
|
| Rate for Payer: Multiplan Commercial |
$257.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$235.45
|
| Rate for Payer: United Healthcare Commercial |
$263.15
|
|
|
ACNE SURGERY
|
Professional
|
Both
|
$110.80
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
5101004001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.78 |
| Max. Negotiated Rate |
$178.97 |
| Rate for Payer: Aetna of VT Commercial |
$104.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.62
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cigna Commercial |
$54.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$178.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$178.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$110.45
|
| Rate for Payer: Multiplan Commercial |
$103.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$69.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare Commercial |
$75.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare VA CCN |
$48.78
|
|
|
ACNE SURGERY
|
Facility
|
IP
|
$110.80
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
5101004001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.00 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna of VT Commercial |
$105.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$82.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$82.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$94.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$93.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$88.64
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cigna Commercial |
$88.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.64
|
| Rate for Payer: Multiplan Commercial |
$103.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.18
|
| Rate for Payer: United Healthcare Commercial |
$105.26
|
|
|
ACNE SURGERY
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Aetna of VT Commercial |
$263.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$122.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$166.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$235.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$224.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$124.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$220.22
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$221.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$221.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$221.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$124.65
|
| Rate for Payer: Multiplan Commercial |
$257.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$235.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$124.65
|
| Rate for Payer: United Healthcare Commercial |
$263.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$124.65
|
| Rate for Payer: United Healthcare VA CCN |
$124.65
|
|
|
ACNE SURGERY
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$48.78 |
| Max. Negotiated Rate |
$260.38 |
| Rate for Payer: Aetna of VT Commercial |
$260.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.62
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$54.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$178.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$178.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$110.45
|
| Rate for Payer: Multiplan Commercial |
$257.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$69.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare Commercial |
$75.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare VA CCN |
$48.78
|
|
|
ACNE SURGERY
|
Professional
|
Both
|
$166.20
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$48.78 |
| Max. Negotiated Rate |
$178.97 |
| Rate for Payer: Aetna of VT Commercial |
$156.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$56.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$143.62
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$54.85
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$178.97
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$178.97
|
| Rate for Payer: Martins Point Health Care Commercial |
$110.45
|
| Rate for Payer: Multiplan Commercial |
$154.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$69.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare Commercial |
$75.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.78
|
| Rate for Payer: United Healthcare VA CCN |
$48.78
|
|
|
ACNE SURGERY
|
Facility
|
IP
|
$166.20
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$123.00 |
| Max. Negotiated Rate |
$157.89 |
| Rate for Payer: Aetna of VT Commercial |
$157.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$123.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$139.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.96
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$132.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.96
|
| Rate for Payer: Multiplan Commercial |
$154.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.27
|
| Rate for Payer: United Healthcare Commercial |
$157.89
|
|
|
ACNE SURGERY
|
Facility
|
OP
|
$166.20
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
9601004002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$73.61 |
| Max. Negotiated Rate |
$157.89 |
| Rate for Payer: Aetna of VT Commercial |
$157.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$148.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$148.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$100.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$134.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$74.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.13
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$132.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$132.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$132.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$74.79
|
| Rate for Payer: Multiplan Commercial |
$154.57
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$74.79
|
| Rate for Payer: United Healthcare Commercial |
$157.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.79
|
| Rate for Payer: United Healthcare VA CCN |
$74.79
|
|
|
ACNE SURGERY
|
Facility
|
OP
|
$110.80
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
5101004001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.07 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna of VT Commercial |
$105.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$49.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$66.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$94.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$89.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$49.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$88.09
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cigna Commercial |
$88.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$88.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$88.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$49.86
|
| Rate for Payer: Multiplan Commercial |
$103.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$49.86
|
| Rate for Payer: United Healthcare Commercial |
$105.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.86
|
| Rate for Payer: United Healthcare VA CCN |
$49.86
|
|
|
ACTIN SMOOTH MUSCLE ANTIBDY EA
|
Facility
|
OP
|
$139.59
|
|
|
Service Code
|
CPT 86015
|
| Hospital Charge Code |
3008601501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$132.61 |
| Rate for Payer: Aetna of VT Commercial |
$132.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$61.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$84.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$118.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$62.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$110.97
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cigna Commercial |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.67
|
| Rate for Payer: Martins Point Health Care Commercial |
$62.82
|
| Rate for Payer: Multiplan Commercial |
$129.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$118.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$62.82
|
| Rate for Payer: United Healthcare Commercial |
$132.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare VA CCN |
$62.82
|
|
|
ACTIN SMOOTH MUSCLE ANTIBDY EA
|
Professional
|
Both
|
$139.59
|
|
|
Service Code
|
CPT 86015
|
| Hospital Charge Code |
3008601501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$131.21 |
| Rate for Payer: Aetna of VT Commercial |
$131.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$59.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$59.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$16.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.60
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cigna Commercial |
$14.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$11.88
|
| Rate for Payer: Multiplan Commercial |
$129.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare Commercial |
$18.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare VA CCN |
$12.05
|
|
|
ACTIN SMOOTH MUSCLE ANTIBDY EA
|
Facility
|
IP
|
$139.59
|
|
|
Service Code
|
CPT 86015
|
| Hospital Charge Code |
3008601501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.31 |
| Max. Negotiated Rate |
$132.61 |
| Rate for Payer: Aetna of VT Commercial |
$132.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$103.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$103.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$118.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$117.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$111.67
|
| Rate for Payer: Cash Price |
$69.80
|
| Rate for Payer: Cigna Commercial |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$111.67
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$111.67
|
| Rate for Payer: Multiplan Commercial |
$129.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$118.65
|
| Rate for Payer: United Healthcare Commercial |
$132.61
|
|
|
ADHESIOLYSIS TUBE OVARY
|
Facility
|
IP
|
$2,095.00
|
|
|
Service Code
|
CPT 58740
|
| Hospital Charge Code |
9825874001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,550.51 |
| Max. Negotiated Rate |
$1,990.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,990.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,550.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,550.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,780.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,759.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,676.00
|
| Rate for Payer: Cash Price |
$1,047.50
|
| Rate for Payer: Cigna Commercial |
$1,676.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,676.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,676.00
|
| Rate for Payer: Multiplan Commercial |
$1,948.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,780.75
|
| Rate for Payer: United Healthcare Commercial |
$1,990.25
|
|
|
ADHESIOLYSIS TUBE OVARY
|
Facility
|
OP
|
$2,095.00
|
|
|
Service Code
|
CPT 58740
|
| Hospital Charge Code |
9825874001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$927.88 |
| Max. Negotiated Rate |
$1,990.25 |
| Rate for Payer: Aetna of VT Commercial |
$1,990.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,876.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$927.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,876.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,261.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,780.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,696.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$942.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,665.53
|
| Rate for Payer: Cash Price |
$1,047.50
|
| Rate for Payer: Cigna Commercial |
$1,676.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,676.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,676.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$942.75
|
| Rate for Payer: Multiplan Commercial |
$1,948.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,780.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$942.75
|
| Rate for Payer: United Healthcare Commercial |
$1,990.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$942.75
|
| Rate for Payer: United Healthcare VA CCN |
$942.75
|
|
|
ADHESIOLYSIS TUBE OVARY
|
Professional
|
Both
|
$2,095.00
|
|
|
Service Code
|
CPT 58740
|
| Hospital Charge Code |
9825874001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$837.54 |
| Max. Negotiated Rate |
$1,969.30 |
| Rate for Payer: Aetna of VT Commercial |
$1,969.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,876.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$862.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,876.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,172.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,460.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,460.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$963.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,460.50
|
| Rate for Payer: Cash Price |
$1,047.50
|
| Rate for Payer: Cash Price |
$1,047.50
|
| Rate for Payer: Cigna Commercial |
$1,473.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,404.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,404.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$837.54
|
| Rate for Payer: Multiplan Commercial |
$1,948.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,189.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$837.54
|
| Rate for Payer: United Healthcare Commercial |
$1,288.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$837.54
|
| Rate for Payer: United Healthcare VA CCN |
$837.54
|
|
|
ADHESIVE .36ML DERMABOND
|
Facility
|
IP
|
$9.20
|
|
| Hospital Charge Code |
2720045741
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna of VT Commercial |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.36
|
| Rate for Payer: Cash Price |
$4.60
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$8.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.82
|
| Rate for Payer: United Healthcare Commercial |
$8.74
|
|
|
ADHESIVE .36ML DERMABOND
|
Facility
|
OP
|
$9.20
|
|
| Hospital Charge Code |
2720045741
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna of VT Commercial |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$8.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$4.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$8.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.31
|
| Rate for Payer: Cash Price |
$4.60
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$7.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$7.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$8.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.82
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4.14
|
| Rate for Payer: United Healthcare Commercial |
$8.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.14
|
| Rate for Payer: United Healthcare VA CCN |
$4.14
|
|
|
ADMIN ECG CONTRAST AGENT
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
CPT 93352
|
| Hospital Charge Code |
4809335201
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$33.46 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna of VT Commercial |
$126.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$55.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$76.67
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$54.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$54.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.46
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.46
|
| Rate for Payer: United Healthcare Commercial |
$51.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.46
|
| Rate for Payer: United Healthcare VA CCN |
$33.46
|
|
|
ADMIN ECG CONTRAST AGENT
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 93352
|
| Hospital Charge Code |
4809335201
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$59.79 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$59.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$81.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.33
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.75
|
| Rate for Payer: United Healthcare VA CCN |
$60.75
|
|
|
ADMIN ECG CONTRAST AGENT
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT 93352
|
| Hospital Charge Code |
4809335201
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$99.91 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna of VT Commercial |
$128.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$113.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.00
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.00
|
| Rate for Payer: Multiplan Commercial |
$125.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$114.75
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
|
|
ADMIN PNEUMOCOCCAL VACCINE
|
Professional
|
Both
|
$40.33
|
|
| Hospital Charge Code |
7710000901
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$37.91 |
| Rate for Payer: Aetna of VT Commercial |
$37.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$36.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$36.13
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Multiplan Commercial |
$37.51
|
| Rate for Payer: United Healthcare Commercial |
$34.28
|
| Rate for Payer: United Healthcare VA CCN |
$16.13
|
|
|
ADMIN PNEUMOCOCCAL VACCINE
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
7710000901
|
|
Hospital Revenue Code
|
771
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.00
|
| Rate for Payer: United Healthcare VA CCN |
$0.00
|
|
|
ADMIN PNEUMOCOCCAL VACCINE
|
Facility
|
IP
|
$0.01
|
|
| Hospital Charge Code |
7710000901
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.01
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
