|
BONE IMAGING 3 PHASE
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
9727831501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$137.75 |
| Rate for Payer: Aetna of VT Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$123.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$121.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$116.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$116.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$116.00
|
| Rate for Payer: Multiplan Commercial |
$134.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$123.25
|
| Rate for Payer: United Healthcare Commercial |
$137.75
|
|
|
BONE IMAGING 3 PHASE
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
9727831501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$134.85 |
| Max. Negotiated Rate |
$1,167.76 |
| Rate for Payer: Aetna of VT Commercial |
$136.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,167.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$306.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,167.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$416.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$464.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$464.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$342.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$464.67
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$461.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$478.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$478.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$297.56
|
| Rate for Payer: Multiplan Commercial |
$134.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$297.56
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$297.56
|
| Rate for Payer: United Healthcare Commercial |
$457.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$297.56
|
| Rate for Payer: United Healthcare VA CCN |
$297.56
|
|
|
BONE &/JOINT IMAGING 3 PHASE S
|
Facility
|
IP
|
$2,548.81
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
3417831501
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,886.37 |
| Max. Negotiated Rate |
$2,421.37 |
| Rate for Payer: Aetna of VT Commercial |
$2,421.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,886.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,886.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,166.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,141.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,039.05
|
| Rate for Payer: Cash Price |
$1,274.40
|
| Rate for Payer: Cigna Commercial |
$2,039.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,039.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,039.05
|
| Rate for Payer: Multiplan Commercial |
$2,370.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,166.49
|
| Rate for Payer: United Healthcare Commercial |
$2,421.37
|
|
|
BONE &/JOINT IMAGING 3 PHASE S
|
Facility
|
OP
|
$2,548.81
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
3417831501
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,128.87 |
| Max. Negotiated Rate |
$2,421.37 |
| Rate for Payer: Aetna of VT Commercial |
$2,421.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,167.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,128.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,167.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,534.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,166.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,064.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,146.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,026.30
|
| Rate for Payer: Cash Price |
$1,274.40
|
| Rate for Payer: Cash Price |
$1,274.40
|
| Rate for Payer: Cigna Commercial |
$2,039.05
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,039.05
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,039.05
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,146.96
|
| Rate for Payer: Multiplan Commercial |
$2,370.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,166.49
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,146.96
|
| Rate for Payer: United Healthcare Commercial |
$2,421.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,146.96
|
| Rate for Payer: United Healthcare VA CCN |
$1,146.96
|
|
|
BONE MARROW IMAGING LTD
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 78102
|
| Hospital Charge Code |
9727810201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$92.57 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna of VT Commercial |
$198.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$187.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$92.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$187.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$125.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$169.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$94.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$166.16
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$167.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.05
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.05
|
| Rate for Payer: United Healthcare Commercial |
$198.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.05
|
| Rate for Payer: United Healthcare VA CCN |
$94.05
|
|
|
BONE MARROW IMAGING LTD
|
Facility
|
OP
|
$1,389.70
|
|
|
Service Code
|
CPT 78102
|
| Hospital Charge Code |
3417810201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$588.74 |
| Max. Negotiated Rate |
$1,320.21 |
| Rate for Payer: Aetna of VT Commercial |
$1,320.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$588.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$615.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$588.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$836.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,181.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,125.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$625.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,104.81
|
| Rate for Payer: Cash Price |
$694.85
|
| Rate for Payer: Cash Price |
$694.85
|
| Rate for Payer: Cigna Commercial |
$1,111.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,111.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,111.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$625.37
|
| Rate for Payer: Multiplan Commercial |
$1,292.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,181.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$625.37
|
| Rate for Payer: United Healthcare Commercial |
$1,320.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$625.37
|
| Rate for Payer: United Healthcare VA CCN |
$625.37
|
|
|
BONE MARROW IMAGING LTD
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 78102
|
| Hospital Charge Code |
9727810201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$154.68 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna of VT Commercial |
$198.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$154.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$154.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$177.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$175.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$167.20
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$167.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$167.20
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.65
|
| Rate for Payer: United Healthcare Commercial |
$198.55
|
|
|
BONE MARROW IMAGING LTD
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 78102
|
| Hospital Charge Code |
9727810201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$152.41 |
| Max. Negotiated Rate |
$588.74 |
| Rate for Payer: Aetna of VT Commercial |
$196.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$588.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$156.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$588.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$213.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$224.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$224.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$175.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$224.57
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$245.32
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$245.32
|
| Rate for Payer: Martins Point Health Care Commercial |
$152.41
|
| Rate for Payer: Multiplan Commercial |
$194.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$152.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$152.42
|
| Rate for Payer: United Healthcare Commercial |
$234.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.42
|
| Rate for Payer: United Healthcare VA CCN |
$152.42
|
|
|
BONE MARROW IMAGING LTD
|
Facility
|
IP
|
$1,389.70
|
|
|
Service Code
|
CPT 78102
|
| Hospital Charge Code |
3417810201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,028.52 |
| Max. Negotiated Rate |
$1,320.21 |
| Rate for Payer: Aetna of VT Commercial |
$1,320.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,028.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,028.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,181.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,167.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,111.76
|
| Rate for Payer: Cash Price |
$694.85
|
| Rate for Payer: Cigna Commercial |
$1,111.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,111.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,111.76
|
| Rate for Payer: Multiplan Commercial |
$1,292.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,181.24
|
| Rate for Payer: United Healthcare Commercial |
$1,320.21
|
|
|
BONE SRGRY CMPTR CT/MRI IMAG
|
Facility
|
IP
|
$1,228.00
|
|
|
Service Code
|
CPT 0055T
|
| Hospital Charge Code |
9820055T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$908.84 |
| Max. Negotiated Rate |
$1,166.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,166.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$908.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$908.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,043.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,031.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$982.40
|
| Rate for Payer: Cash Price |
$614.00
|
| Rate for Payer: Cigna Commercial |
$982.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$982.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$982.40
|
| Rate for Payer: Multiplan Commercial |
$1,142.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,043.80
|
| Rate for Payer: United Healthcare Commercial |
$1,166.60
|
|
|
BONE SRGRY CMPTR CT/MRI IMAG
|
Facility
|
OP
|
$1,228.00
|
|
|
Service Code
|
CPT 0055T
|
| Hospital Charge Code |
9820055T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$543.88 |
| Max. Negotiated Rate |
$1,166.60 |
| Rate for Payer: Aetna of VT Commercial |
$1,166.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,100.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$543.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,100.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$739.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,043.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$994.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$552.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$976.26
|
| Rate for Payer: Cash Price |
$614.00
|
| Rate for Payer: Cigna Commercial |
$982.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$982.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$982.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$552.60
|
| Rate for Payer: Multiplan Commercial |
$1,142.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,043.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$552.60
|
| Rate for Payer: United Healthcare Commercial |
$1,166.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$552.60
|
| Rate for Payer: United Healthcare VA CCN |
$552.60
|
|
|
BONE SRGRY CMPTR CT/MRI IMAG
|
Professional
|
Both
|
$1,228.00
|
|
|
Service Code
|
CPT 0055T
|
| Hospital Charge Code |
9820055T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$1,154.32 |
| Rate for Payer: Aetna of VT Commercial |
$1,154.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,100.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,100.17
|
| Rate for Payer: Cash Price |
$614.00
|
| Rate for Payer: Cash Price |
$614.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Multiplan Commercial |
$1,142.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$491.20
|
|
|
BONE SRGRY CMPTR FLUOR IMAGE
|
Professional
|
Both
|
$662.00
|
|
|
Service Code
|
CPT 0054T
|
| Hospital Charge Code |
9820054T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$622.28 |
| Rate for Payer: Aetna of VT Commercial |
$622.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$593.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$593.09
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$72.06
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$72.06
|
| Rate for Payer: Multiplan Commercial |
$615.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$45.00
|
| Rate for Payer: United Healthcare Commercial |
$58.35
|
| Rate for Payer: United Healthcare VA CCN |
$264.80
|
|
|
BONE SRGRY CMPTR FLUOR IMAGE
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
CPT 0054T
|
| Hospital Charge Code |
9820054T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$489.95 |
| Max. Negotiated Rate |
$628.90 |
| Rate for Payer: Aetna of VT Commercial |
$628.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$489.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$489.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$562.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$556.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$529.60
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$529.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$529.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$529.60
|
| Rate for Payer: Multiplan Commercial |
$615.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$562.70
|
| Rate for Payer: United Healthcare Commercial |
$628.90
|
|
|
BONE SRGRY CMPTR FLUOR IMAGE
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
CPT 0054T
|
| Hospital Charge Code |
9820054T01
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$293.20 |
| Max. Negotiated Rate |
$628.90 |
| Rate for Payer: Aetna of VT Commercial |
$628.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$593.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$293.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$593.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$398.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$562.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$536.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$297.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$526.29
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$529.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$529.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$529.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$297.90
|
| Rate for Payer: Multiplan Commercial |
$615.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$562.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$297.90
|
| Rate for Payer: United Healthcare Commercial |
$628.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$297.90
|
| Rate for Payer: United Healthcare VA CCN |
$297.90
|
|
|
BORDETELLA ANTIBODY
|
Facility
|
IP
|
$316.40
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3008661501
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
BORDETELLA ANTIBODY
|
Professional
|
Both
|
$316.40
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3008661501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$297.42 |
| Rate for Payer: Aetna of VT Commercial |
$297.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$22.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$22.55
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cigna Commercial |
$15.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.01
|
| Rate for Payer: Multiplan Commercial |
$294.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.19
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare Commercial |
$20.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$13.19
|
|
|
BORDETELLA ANTIBODY
|
Facility
|
OP
|
$316.40
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3008661501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.19 |
| 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 |
$64.99
|
| 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 |
$64.99
|
| 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: 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 |
$13.19
|
| Rate for Payer: United Healthcare VA CCN |
$142.38
|
|
|
BORRELIA MIYAMOTOI AMP PRB
|
Professional
|
Both
|
$86.86
|
|
|
Service Code
|
CPT 87478
|
| Hospital Charge Code |
3008747801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.60 |
| Max. Negotiated Rate |
$172.91 |
| Rate for Payer: Aetna of VT Commercial |
$81.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$49.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.35
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cigna Commercial |
$42.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$48.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$48.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.60
|
| Rate for Payer: Multiplan Commercial |
$80.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare Commercial |
$53.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$35.09
|
|
|
BORRELIA MIYAMOTOI AMP PRB
|
Facility
|
OP
|
$86.86
|
|
|
Service Code
|
CPT 87478
|
| Hospital Charge Code |
3008747801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$172.91 |
| Rate for Payer: Aetna of VT Commercial |
$82.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$52.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$70.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$39.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$69.05
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cigna Commercial |
$69.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$69.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$69.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$39.09
|
| Rate for Payer: Multiplan Commercial |
$80.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.83
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$39.09
|
| Rate for Payer: United Healthcare Commercial |
$82.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare VA CCN |
$39.09
|
|
|
BORRELIA MIYAMOTOI AMP PRB
|
Facility
|
IP
|
$86.86
|
|
|
Service Code
|
CPT 87478
|
| Hospital Charge Code |
3008747801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.29 |
| Max. Negotiated Rate |
$82.52 |
| Rate for Payer: Aetna of VT Commercial |
$82.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$73.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$69.49
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cigna Commercial |
$69.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$69.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$69.49
|
| Rate for Payer: Multiplan Commercial |
$80.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$73.83
|
| Rate for Payer: United Healthcare Commercial |
$82.52
|
|
|
BOTOX 100 UNIT VIAL
|
Facility
|
OP
|
$17.82
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
636J058501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.82
|
|
|
BOTOX 100 UNIT VIAL
|
Professional
|
Both
|
$655.56
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
636J058501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$616.23 |
| Rate for Payer: Aetna of VT Commercial |
$616.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.47
|
| Rate for Payer: Cash Price |
$327.78
|
| Rate for Payer: Cash Price |
$327.78
|
| 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 |
$6.48
|
| Rate for Payer: Multiplan Commercial |
$609.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.50
|
| Rate for Payer: United Healthcare Commercial |
$10.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Healthcare VA CCN |
$6.50
|
|
|
BOTOX 200 UNIT VIAL
|
Facility
|
OP
|
$17.82
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
636J058502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.82
|
|
|
BOTOX 200 UNIT VIAL
|
Professional
|
Both
|
$1,311.11
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
636J058502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$1,232.44 |
| Rate for Payer: Aetna of VT Commercial |
$1,232.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.47
|
| Rate for Payer: Cash Price |
$655.56
|
| Rate for Payer: Cash Price |
$655.56
|
| 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 |
$6.48
|
| Rate for Payer: Multiplan Commercial |
$1,219.33
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.50
|
| Rate for Payer: United Healthcare Commercial |
$10.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.50
|
| Rate for Payer: United Healthcare VA CCN |
$6.50
|
|
