|
CLEAR OUTER EAR CANAL
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 69200
|
| Hospital Charge Code |
9816920001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$99.21 |
| Max. Negotiated Rate |
$212.80 |
| Rate for Payer: Aetna of VT Commercial |
$212.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$200.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$99.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$200.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$134.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$190.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$181.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$178.08
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cigna Commercial |
$179.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$179.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$179.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$100.80
|
| Rate for Payer: Multiplan Commercial |
$208.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$190.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$100.80
|
| Rate for Payer: United Healthcare Commercial |
$212.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.80
|
| Rate for Payer: United Healthcare VA CCN |
$100.80
|
|
|
CLEAR OUTER EAR CANAL
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
CPT 69200
|
| Hospital Charge Code |
9606920001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$182.92 |
| Max. Negotiated Rate |
$392.35 |
| Rate for Payer: Aetna of VT Commercial |
$392.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$182.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$248.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$334.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$185.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$328.33
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cigna Commercial |
$330.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$330.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$330.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$185.85
|
| Rate for Payer: Multiplan Commercial |
$384.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$185.85
|
| Rate for Payer: United Healthcare Commercial |
$392.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$185.85
|
| Rate for Payer: United Healthcare VA CCN |
$185.85
|
|
|
CLEAR OUTER EAR CANAL
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 69200
|
| Hospital Charge Code |
9606920002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$120.47 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna of VT Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$243.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$120.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$243.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$163.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$231.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$220.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$216.24
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cigna Commercial |
$217.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$217.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$217.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$122.40
|
| Rate for Payer: Multiplan Commercial |
$252.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$231.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$122.40
|
| Rate for Payer: United Healthcare Commercial |
$258.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.40
|
| Rate for Payer: United Healthcare VA CCN |
$122.40
|
|
|
CLEAR OUTER EAR CANAL
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 69200
|
| Hospital Charge Code |
9816920002
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$201.31 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna of VT Commercial |
$258.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$201.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$201.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$231.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$228.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$217.60
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cigna Commercial |
$217.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$217.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$217.60
|
| Rate for Payer: Multiplan Commercial |
$252.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$231.20
|
| Rate for Payer: United Healthcare Commercial |
$258.40
|
|
|
CLINDAMYCIN 600 MG/50 ML PREMI
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 338954924
|
| Hospital Charge Code |
636J073701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Aetna of VT Commercial |
$7.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$7.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$7.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.34
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$6.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$7.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.59
|
| Rate for Payer: United Healthcare Commercial |
$7.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.59
|
| Rate for Payer: United Healthcare VA CCN |
$3.59
|
|
|
CLINDAMYCIN 600 MG/50 ML PREMI
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 338954924
|
| Hospital Charge Code |
636J073701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Aetna of VT Commercial |
$7.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$5.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$5.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$6.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$6.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$6.38
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$6.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.38
|
| Rate for Payer: Multiplan Commercial |
$7.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.78
|
| Rate for Payer: United Healthcare Commercial |
$7.58
|
|
|
CLINDAMYCIN 900 MG/50 ML PREMI
|
Facility
|
OP
|
$15.85
|
|
|
Service Code
|
NDC 338381424
|
| Hospital Charge Code |
636J073601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Aetna of VT Commercial |
$15.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$14.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$14.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$12.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.60
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna Commercial |
$12.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.68
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.13
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.13
|
| Rate for Payer: United Healthcare Commercial |
$15.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.13
|
| Rate for Payer: United Healthcare VA CCN |
$7.13
|
|
|
CLINDAMYCIN 900 MG/50 ML PREMI
|
Facility
|
IP
|
$15.85
|
|
|
Service Code
|
NDC 338381424
|
| Hospital Charge Code |
636J073601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.73 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Aetna of VT Commercial |
$15.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$11.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$11.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.68
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna Commercial |
$12.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.68
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.68
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.47
|
| Rate for Payer: United Healthcare Commercial |
$15.06
|
|
|
CLINIMIX E 4.25/10%
|
Facility
|
OP
|
$45.64
|
|
| Hospital Charge Code |
2580000022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$43.36 |
| Rate for Payer: Aetna of VT Commercial |
$43.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$27.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.28
|
| Rate for Payer: Cash Price |
$22.82
|
| Rate for Payer: Cigna Commercial |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$36.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$20.54
|
| Rate for Payer: United Healthcare Commercial |
$43.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.54
|
| Rate for Payer: United Healthcare VA CCN |
$20.54
|
|
|
CLINIMIX E 4.25/10%
|
Facility
|
IP
|
$45.64
|
|
|
Service Code
|
NDC 338111504
|
| Hospital Charge Code |
2580000022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.78 |
| Max. Negotiated Rate |
$43.36 |
| Rate for Payer: Aetna of VT Commercial |
$43.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$38.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.51
|
| Rate for Payer: Cash Price |
$22.82
|
| Rate for Payer: Cigna Commercial |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$36.51
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.79
|
| Rate for Payer: United Healthcare Commercial |
$43.36
|
|
|
CLINIMIX E 4.25/10%
|
Facility
|
OP
|
$45.64
|
|
|
Service Code
|
NDC 338111504
|
| Hospital Charge Code |
2580000022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$43.36 |
| Rate for Payer: Aetna of VT Commercial |
$43.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$40.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$40.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$27.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$36.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.28
|
| Rate for Payer: Cash Price |
$22.82
|
| Rate for Payer: Cigna Commercial |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$36.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$20.54
|
| Rate for Payer: United Healthcare Commercial |
$43.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.54
|
| Rate for Payer: United Healthcare VA CCN |
$20.54
|
|
|
CLINIMIX E 4.25/10%
|
Facility
|
IP
|
$45.64
|
|
| Hospital Charge Code |
2580000022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.78 |
| Max. Negotiated Rate |
$43.36 |
| Rate for Payer: Aetna of VT Commercial |
$43.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$33.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$33.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$38.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$38.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$36.51
|
| Rate for Payer: Cash Price |
$22.82
|
| Rate for Payer: Cigna Commercial |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$36.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$36.51
|
| Rate for Payer: Multiplan Commercial |
$42.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.79
|
| Rate for Payer: United Healthcare Commercial |
$43.36
|
|
|
CLOBETASOL PROP 0.05% OINT 15G
|
Facility
|
IP
|
$16.20
|
|
| Hospital Charge Code |
2500000585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of VT Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.96
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.96
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.77
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
|
|
CLOBETASOL PROP 0.05% OINT 15G
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 4229107715
|
| Hospital Charge Code |
2500000585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of VT Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$14.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$14.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.29
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.29
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.29
|
| Rate for Payer: United Healthcare VA CCN |
$7.29
|
|
|
CLOBETASOL PROP 0.05% OINT 15G
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 4229107715
|
| Hospital Charge Code |
2500000585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of VT Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.96
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.96
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.77
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
|
|
CLOBETASOL PROP 0.05% OINT 15G
|
Facility
|
OP
|
$16.20
|
|
| Hospital Charge Code |
2500000585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of VT Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$14.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$7.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$14.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$9.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$7.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$12.96
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$12.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.29
|
| Rate for Payer: Multiplan Commercial |
$15.07
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.29
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.29
|
| Rate for Payer: United Healthcare VA CCN |
$7.29
|
|
|
CLOSED TX CALCANEAL FRACTURE
|
Professional
|
Both
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9822840001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$226.58 |
| Max. Negotiated Rate |
$517.94 |
| Rate for Payer: Aetna of VT Commercial |
$517.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$233.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$317.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$460.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$460.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$260.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$460.63
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$429.31
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$399.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$399.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$244.24
|
| Rate for Payer: Multiplan Commercial |
$512.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$321.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$226.58
|
| Rate for Payer: United Healthcare Commercial |
$348.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$226.58
|
| Rate for Payer: United Healthcare VA CCN |
$226.58
|
|
|
CLOSED TX CALCANEAL FRACTURE
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9822840001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$244.04 |
| Max. Negotiated Rate |
$523.45 |
| Rate for Payer: Aetna of VT Commercial |
$523.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$244.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$331.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$468.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$446.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$247.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$438.05
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$440.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$440.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$440.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.95
|
| Rate for Payer: Multiplan Commercial |
$512.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$468.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$247.95
|
| Rate for Payer: United Healthcare Commercial |
$523.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$247.95
|
| Rate for Payer: United Healthcare VA CCN |
$247.95
|
|
|
CLOSED TX CALCANEAL FRACTURE
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9822840001
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$407.80 |
| Max. Negotiated Rate |
$523.45 |
| Rate for Payer: Aetna of VT Commercial |
$523.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$407.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$407.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$468.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$462.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$440.80
|
| Rate for Payer: Cash Price |
$275.50
|
| Rate for Payer: Cigna Commercial |
$440.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$440.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$440.80
|
| Rate for Payer: Multiplan Commercial |
$512.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$468.35
|
| Rate for Payer: United Healthcare Commercial |
$523.45
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
5102843001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$96.21 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Aetna of VT Commercial |
$123.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$96.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$96.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$110.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$104.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$104.00
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$110.50
|
| Rate for Payer: United Healthcare Commercial |
$123.50
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9602843001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$207.61 |
| Max. Negotiated Rate |
$407.68 |
| Rate for Payer: Aetna of VT Commercial |
$344.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$213.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$290.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$407.68
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cigna Commercial |
$392.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$236.52
|
| Rate for Payer: Multiplan Commercial |
$341.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare Commercial |
$319.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare VA CCN |
$207.61
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Professional
|
Both
|
$130.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
5102843001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.47 |
| Max. Negotiated Rate |
$407.68 |
| Rate for Payer: Aetna of VT Commercial |
$122.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$213.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$290.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$407.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$238.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$407.68
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$392.44
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$386.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$386.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$236.52
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$294.81
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare Commercial |
$319.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.61
|
| Rate for Payer: United Healthcare VA CCN |
$207.61
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
5102843001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.58 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Aetna of VT Commercial |
$123.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$116.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$57.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$116.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$78.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$110.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$105.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$103.35
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$104.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$110.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$58.50
|
| Rate for Payer: United Healthcare Commercial |
$123.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$58.50
|
| Rate for Payer: United Healthcare VA CCN |
$58.50
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9602843001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$162.54 |
| Max. Negotiated Rate |
$348.65 |
| Rate for Payer: Aetna of VT Commercial |
$348.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$328.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$220.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$311.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$297.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$165.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$291.76
|
| Rate for Payer: Cash Price |
$183.50
|
| Rate for Payer: Cigna Commercial |
$293.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$293.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$293.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$165.15
|
| Rate for Payer: Multiplan Commercial |
$341.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$311.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$165.15
|
| Rate for Payer: United Healthcare Commercial |
$348.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$165.15
|
| Rate for Payer: United Healthcare VA CCN |
$165.15
|
|
|
CLOSED TX TALUS FRACTURE W/O M
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9602843002
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$176.14 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna of VT Commercial |
$226.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$176.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$202.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$199.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$190.40
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$190.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$190.40
|
| Rate for Payer: Multiplan Commercial |
$221.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$202.30
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
|
