|
BUPIVACAINE-MPF 0.25%10ML VIAL
|
Facility
|
OP
|
$11.01
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Aetna of VT Commercial |
$10.46
|
| 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 |
$4.88
|
| 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 |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$9.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$8.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$8.75
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$8.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$8.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$8.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$10.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$9.36
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$4.95
|
| Rate for Payer: United Healthcare Commercial |
$10.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.95
|
| Rate for Payer: United Healthcare VA CCN |
$4.95
|
|
|
BUPIVACAINE-MPF 0.5% 10 ML VIA
|
Professional
|
Both
|
$6.85
|
|
| Hospital Charge Code |
2500000047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna of VT Commercial |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$6.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$6.14
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: United Healthcare Commercial |
$5.82
|
| Rate for Payer: United Healthcare VA CCN |
$2.74
|
|
|
BUPIVACAINE-MPF 0.5% 10ML VIAL
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna of VT Commercial |
$3.16
|
| 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 |
$1.47
|
| 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 |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2.65
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2.66
|
| Rate for Payer: Martins Point Health Care Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.83
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1.50
|
| Rate for Payer: United Healthcare Commercial |
$3.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.50
|
| Rate for Payer: United Healthcare VA CCN |
$1.50
|
|
|
BUPIVACAINE-MPF 0.5% 10ML VIAL
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna of VT Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2.66
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2.66
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2.66
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2.83
|
| Rate for Payer: United Healthcare Commercial |
$3.16
|
|
|
BUPIVACAINE-MPF 0.5% 30ML VIAL
|
Facility
|
IP
|
$4.79
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna of VT Commercial |
$4.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.83
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.07
|
| Rate for Payer: United Healthcare Commercial |
$4.55
|
|
|
BUPIVACAINE-MPF 0.5% 30ML VIAL
|
Facility
|
OP
|
$4.79
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna of VT Commercial |
$4.55
|
| 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 |
$2.12
|
| 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 |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.81
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.83
|
| Rate for Payer: Martins Point Health Care Commercial |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.07
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2.16
|
| Rate for Payer: United Healthcare Commercial |
$4.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.16
|
| Rate for Payer: United Healthcare VA CCN |
$2.16
|
|
|
BUPIV-MPF 0.25% W/EPI 30ML VIA
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Aetna of VT Commercial |
$16.15
|
| 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 |
$7.53
|
| 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 |
$10.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$14.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.52
|
| Rate for Payer: Cash Price |
$8.50
|
| Rate for Payer: Cash Price |
$8.50
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.65
|
| Rate for Payer: United Healthcare Commercial |
$16.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.65
|
| Rate for Payer: United Healthcare VA CCN |
$7.65
|
|
|
BUPIV-MPF 0.25% W/EPI 30ML VIA
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Aetna of VT Commercial |
$16.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$14.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$14.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.60
|
| Rate for Payer: Cash Price |
$8.50
|
| Rate for Payer: Cigna Commercial |
$13.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.60
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.45
|
| Rate for Payer: United Healthcare Commercial |
$16.15
|
|
|
BUPIV-MPF 0.5 W/ EPI 30ML VIAL
|
Facility
|
OP
|
$31.14
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$29.58 |
| Rate for Payer: Aetna of VT Commercial |
$29.58
|
| 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 |
$13.79
|
| 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 |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$26.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$25.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$24.76
|
| Rate for Payer: Cash Price |
$15.57
|
| Rate for Payer: Cash Price |
$15.57
|
| Rate for Payer: Cigna Commercial |
$24.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$24.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$24.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$14.01
|
| Rate for Payer: Multiplan Commercial |
$28.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$26.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$14.01
|
| Rate for Payer: United Healthcare Commercial |
$29.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.01
|
| Rate for Payer: United Healthcare VA CCN |
$14.01
|
|
|
BUPIV-MPF 0.5 W/ EPI 30ML VIAL
|
Facility
|
IP
|
$31.14
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636J066506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.05 |
| Max. Negotiated Rate |
$29.58 |
| Rate for Payer: Aetna of VT Commercial |
$29.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$23.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$23.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$26.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$24.91
|
| Rate for Payer: Cash Price |
$15.57
|
| Rate for Payer: Cigna Commercial |
$24.91
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$24.91
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$24.91
|
| Rate for Payer: Multiplan Commercial |
$28.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$26.47
|
| Rate for Payer: United Healthcare Commercial |
$29.58
|
|
|
BUPRENORPH XR 100 MG OR LESS
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT Q9991
|
| Hospital Charge Code |
636Q999101
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$5,294.38 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,294.38
|
| 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 |
$5,294.38
|
| 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
|
|
|
BUPRENORPH XR 100 MG OR LESS
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT Q9991
|
| Hospital Charge Code |
636Q999101
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
BUPRENORPH XR 100 MG OR LESS
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
CPT Q9991
|
| Hospital Charge Code |
636Q999101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5,294.38 |
| Rate for Payer: Aetna of VT Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,294.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,076.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,294.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,822.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,318.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,931.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,931.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,925.23
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,016.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,016.42
|
| Rate for Payer: United Healthcare Commercial |
$3,101.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,016.42
|
| Rate for Payer: United Healthcare VA CCN |
$2,016.42
|
|
|
BUTORPHANOL 2 MG/ML VIAL
|
Professional
|
Both
|
$46.55
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
636J059501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$43.76 |
| Rate for Payer: Aetna of VT Commercial |
$43.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$12.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$6.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$12.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.39
|
| Rate for Payer: Cash Price |
$23.27
|
| Rate for Payer: Cash Price |
$23.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$4.69
|
| Rate for Payer: Multiplan Commercial |
$43.29
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.43
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$6.43
|
| Rate for Payer: United Healthcare Commercial |
$9.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.43
|
| Rate for Payer: United Healthcare VA CCN |
$6.43
|
|
|
BUTORPHANOL 2 MG/ML VIAL
|
Facility
|
OP
|
$12.90
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
636J059501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$12.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$12.90
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
IP
|
$6,558.66
|
|
|
Service Code
|
CPT 19081
|
| Hospital Charge Code |
3201908101
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$4,854.06 |
| Max. Negotiated Rate |
$6,230.73 |
| Rate for Payer: Aetna of VT Commercial |
$6,230.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$4,854.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$4,854.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,574.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,509.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,246.93
|
| Rate for Payer: Cash Price |
$3,279.33
|
| Rate for Payer: Cigna Commercial |
$5,246.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,246.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,246.93
|
| Rate for Payer: Multiplan Commercial |
$6,099.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,574.86
|
| Rate for Payer: United Healthcare Commercial |
$6,230.73
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
IP
|
$1,956.00
|
|
|
Service Code
|
CPT 19081 26
|
| Hospital Charge Code |
9721908101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$1,447.64 |
| Max. Negotiated Rate |
$1,858.20 |
| Rate for Payer: Aetna of VT Commercial |
$1,858.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,447.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,447.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,662.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,643.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,564.80
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$1,564.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,564.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,564.80
|
| Rate for Payer: Multiplan Commercial |
$1,819.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,662.60
|
| Rate for Payer: United Healthcare Commercial |
$1,858.20
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Professional
|
Both
|
$1,956.00
|
|
|
Service Code
|
CPT 19081 26
|
| Hospital Charge Code |
9721908101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$247.89 |
| Max. Negotiated Rate |
$1,838.64 |
| Rate for Payer: Aetna of VT Commercial |
$1,838.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,752.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,752.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$998.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$998.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$998.38
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$275.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$463.35
|
| Rate for Payer: Multiplan Commercial |
$1,819.08
|
| Rate for Payer: United Healthcare Commercial |
$1,662.60
|
| Rate for Payer: United Healthcare VA CCN |
$782.40
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
OP
|
$1,956.00
|
|
|
Service Code
|
CPT 19081 26
|
| Hospital Charge Code |
9721908101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$866.31 |
| Max. Negotiated Rate |
$1,858.20 |
| Rate for Payer: Aetna of VT Commercial |
$1,858.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,752.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$866.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,752.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,177.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,662.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,584.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$880.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,555.02
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$1,564.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,564.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,564.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$880.20
|
| Rate for Payer: Multiplan Commercial |
$1,819.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,662.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$880.20
|
| Rate for Payer: United Healthcare Commercial |
$1,858.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$880.20
|
| Rate for Payer: United Healthcare VA CCN |
$880.20
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
OP
|
$3,389.74
|
|
|
Service Code
|
CPT 19081 RT
|
| Hospital Charge Code |
32019081RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,501.32 |
| Max. Negotiated Rate |
$3,220.25 |
| Rate for Payer: Aetna of VT Commercial |
$3,220.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,036.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,501.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,036.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,040.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,881.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,745.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,525.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,694.84
|
| Rate for Payer: Cash Price |
$1,694.87
|
| Rate for Payer: Cigna Commercial |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,711.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,525.38
|
| Rate for Payer: Multiplan Commercial |
$3,152.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,881.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,525.38
|
| Rate for Payer: United Healthcare Commercial |
$3,220.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,525.38
|
| Rate for Payer: United Healthcare VA CCN |
$1,525.38
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
OP
|
$6,558.66
|
|
|
Service Code
|
CPT 19081
|
| Hospital Charge Code |
3201908101
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,904.83 |
| Max. Negotiated Rate |
$6,230.73 |
| Rate for Payer: Aetna of VT Commercial |
$6,230.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5,875.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,904.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5,875.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$3,948.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$5,574.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$5,312.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,951.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$5,214.13
|
| Rate for Payer: Cash Price |
$3,279.33
|
| Rate for Payer: Cigna Commercial |
$5,246.93
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5,246.93
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5,246.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,951.40
|
| Rate for Payer: Multiplan Commercial |
$6,099.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5,574.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,951.40
|
| Rate for Payer: United Healthcare Commercial |
$6,230.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,951.40
|
| Rate for Payer: United Healthcare VA CCN |
$2,951.40
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
OP
|
$3,389.74
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
32019081LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,501.32 |
| Max. Negotiated Rate |
$3,220.25 |
| Rate for Payer: Aetna of VT Commercial |
$3,220.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,036.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,501.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,036.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,040.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,881.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,745.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,525.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,694.84
|
| Rate for Payer: Cash Price |
$1,694.87
|
| Rate for Payer: Cigna Commercial |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,711.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,525.38
|
| Rate for Payer: Multiplan Commercial |
$3,152.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,881.28
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,525.38
|
| Rate for Payer: United Healthcare Commercial |
$3,220.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,525.38
|
| Rate for Payer: United Healthcare VA CCN |
$1,525.38
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
IP
|
$3,389.74
|
|
|
Service Code
|
CPT 19081 LT
|
| Hospital Charge Code |
32019081LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,508.75 |
| Max. Negotiated Rate |
$3,220.25 |
| Rate for Payer: Aetna of VT Commercial |
$3,220.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,508.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,508.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,881.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,847.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,711.79
|
| Rate for Payer: Cash Price |
$1,694.87
|
| Rate for Payer: Cigna Commercial |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,711.79
|
| Rate for Payer: Multiplan Commercial |
$3,152.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,881.28
|
| Rate for Payer: United Healthcare Commercial |
$3,220.25
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
IP
|
$3,389.74
|
|
|
Service Code
|
CPT 19081 RT
|
| Hospital Charge Code |
32019081RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,508.75 |
| Max. Negotiated Rate |
$3,220.25 |
| Rate for Payer: Aetna of VT Commercial |
$3,220.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,508.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,508.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,881.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,847.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,711.79
|
| Rate for Payer: Cash Price |
$1,694.87
|
| Rate for Payer: Cigna Commercial |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,711.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,711.79
|
| Rate for Payer: Multiplan Commercial |
$3,152.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,881.28
|
| Rate for Payer: United Healthcare Commercial |
$3,220.25
|
|
|
BX BREAST 1ST LESION US IMAG
|
Professional
|
Both
|
$1,711.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9721908301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$248.98 |
| Max. Negotiated Rate |
$1,608.34 |
| Rate for Payer: Aetna of VT Commercial |
$1,608.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.13
|
| Rate for Payer: Cash Price |
$855.50
|
| Rate for Payer: Cash Price |
$855.50
|
| Rate for Payer: Cigna Commercial |
$370.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.98
|
| Rate for Payer: Multiplan Commercial |
$1,591.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$248.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare Commercial |
$383.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare VA CCN |
$248.98
|
|
