|
CLOT INHIBIT PROT C ACTIVITY
|
Professional
|
Both
|
$249.97
|
|
|
Service Code
|
CPT 85303
|
| Hospital Charge Code |
3008530301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.65 |
| Max. Negotiated Rate |
$234.97 |
| Rate for Payer: Aetna of VT Commercial |
$234.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$68.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$68.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.66
|
| Rate for Payer: Cash Price |
$124.98
|
| Rate for Payer: Cash Price |
$124.98
|
| Rate for Payer: Cigna Commercial |
$16.66
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$13.84
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$13.84
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.65
|
| Rate for Payer: Multiplan Commercial |
$232.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.84
|
| Rate for Payer: United Healthcare Commercial |
$21.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.84
|
| Rate for Payer: United Healthcare VA CCN |
$13.84
|
|
|
CLOT INHIBIT PROT C ACTIVITY
|
Facility
|
OP
|
$249.97
|
|
|
Service Code
|
CPT 85303
|
| Hospital Charge Code |
3008530301
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$237.47 |
| Rate for Payer: Aetna of VT Commercial |
$237.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$68.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$110.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$68.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$150.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$202.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$112.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$198.73
|
| Rate for Payer: Cash Price |
$124.98
|
| Rate for Payer: Cash Price |
$124.98
|
| Rate for Payer: Cigna Commercial |
$199.98
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$199.98
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$199.98
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.49
|
| Rate for Payer: Multiplan Commercial |
$232.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$212.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$112.49
|
| Rate for Payer: United Healthcare Commercial |
$237.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.84
|
| Rate for Payer: United Healthcare VA CCN |
$112.49
|
|
|
CLOTTING FACTOR VIII AHG 1 ST
|
Facility
|
OP
|
$324.68
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
3008524001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$308.45 |
| Rate for Payer: Aetna of VT Commercial |
$308.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$143.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$195.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$275.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$262.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$146.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$258.12
|
| Rate for Payer: Cash Price |
$162.34
|
| Rate for Payer: Cash Price |
$162.34
|
| Rate for Payer: Cigna Commercial |
$259.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$259.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$259.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$146.11
|
| Rate for Payer: Multiplan Commercial |
$301.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$275.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$146.11
|
| Rate for Payer: United Healthcare Commercial |
$308.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare VA CCN |
$146.11
|
|
|
CLOTTING FACTOR VIII AHG 1 ST
|
Professional
|
Both
|
$324.68
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
3008524001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$305.20 |
| Rate for Payer: Aetna of VT Commercial |
$305.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.60
|
| Rate for Payer: Cash Price |
$162.34
|
| Rate for Payer: Cash Price |
$162.34
|
| Rate for Payer: Cigna Commercial |
$21.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.65
|
| Rate for Payer: Multiplan Commercial |
$301.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare Commercial |
$27.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare VA CCN |
$17.90
|
|
|
CLOTTING FACTOR VIII AHG 1 ST
|
Facility
|
IP
|
$324.68
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
3008524001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$240.30 |
| Max. Negotiated Rate |
$308.45 |
| Rate for Payer: Aetna of VT Commercial |
$308.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$240.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$240.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$275.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$272.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$259.74
|
| Rate for Payer: Cash Price |
$162.34
|
| Rate for Payer: Cigna Commercial |
$259.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$259.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$259.74
|
| Rate for Payer: Multiplan Commercial |
$301.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$275.98
|
| Rate for Payer: United Healthcare Commercial |
$308.45
|
|
|
CLOTTING FACTOR XI PTA
|
Facility
|
IP
|
$229.55
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
3008527001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.89 |
| Max. Negotiated Rate |
$218.07 |
| Rate for Payer: Aetna of VT Commercial |
$218.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$169.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$169.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$192.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.64
|
| Rate for Payer: Cash Price |
$114.78
|
| Rate for Payer: Cigna Commercial |
$183.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.64
|
| Rate for Payer: Multiplan Commercial |
$213.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.12
|
| Rate for Payer: United Healthcare Commercial |
$218.07
|
|
|
CLOTTING FACTOR XI PTA
|
Professional
|
Both
|
$229.55
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
3008527001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$215.78 |
| Rate for Payer: Aetna of VT Commercial |
$215.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$20.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.60
|
| Rate for Payer: Cash Price |
$114.78
|
| Rate for Payer: Cash Price |
$114.78
|
| Rate for Payer: Cigna Commercial |
$21.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$17.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$17.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$17.65
|
| Rate for Payer: Multiplan Commercial |
$213.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$17.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare Commercial |
$27.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare VA CCN |
$17.90
|
|
|
CLOTTING FACTOR XI PTA
|
Facility
|
OP
|
$229.55
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
3008527001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$218.07 |
| Rate for Payer: Aetna of VT Commercial |
$218.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.49
|
| Rate for Payer: Cash Price |
$114.78
|
| Rate for Payer: Cash Price |
$114.78
|
| Rate for Payer: Cigna Commercial |
$183.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.30
|
| Rate for Payer: Multiplan Commercial |
$213.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.30
|
| Rate for Payer: United Healthcare Commercial |
$218.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare VA CCN |
$103.30
|
|
|
CLOTTING FUNCT ACTIVITY
|
Professional
|
Both
|
$230.32
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
3008539701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$216.50 |
| Rate for Payer: Aetna of VT Commercial |
$216.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$152.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$31.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$152.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$48.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$35.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.44
|
| Rate for Payer: Cash Price |
$115.16
|
| Rate for Payer: Cash Price |
$115.16
|
| Rate for Payer: Cigna Commercial |
$37.29
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$30.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$30.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$30.43
|
| Rate for Payer: Multiplan Commercial |
$214.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$30.86
|
| Rate for Payer: United Healthcare Commercial |
$47.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.86
|
| Rate for Payer: United Healthcare VA CCN |
$30.86
|
|
|
CLOTTING FUNCT ACTIVITY
|
Facility
|
OP
|
$230.32
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
3008539701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.86 |
| Max. Negotiated Rate |
$218.80 |
| Rate for Payer: Aetna of VT Commercial |
$218.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$152.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$102.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$152.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$186.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.10
|
| Rate for Payer: Cash Price |
$115.16
|
| Rate for Payer: Cash Price |
$115.16
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.64
|
| Rate for Payer: Multiplan Commercial |
$214.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.64
|
| Rate for Payer: United Healthcare Commercial |
$218.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.86
|
| Rate for Payer: United Healthcare VA CCN |
$103.64
|
|
|
CLOTTING FUNCT ACTIVITY
|
Facility
|
IP
|
$230.32
|
|
|
Service Code
|
CPT 85397
|
| Hospital Charge Code |
3008539701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$170.46 |
| Max. Negotiated Rate |
$218.80 |
| Rate for Payer: Aetna of VT Commercial |
$218.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$193.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.26
|
| Rate for Payer: Cash Price |
$115.16
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.26
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.26
|
| Rate for Payer: Multiplan Commercial |
$214.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.77
|
| Rate for Payer: United Healthcare Commercial |
$218.80
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 6586284601
|
| Hospital Charge Code |
2500000589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna of VT Commercial |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.49
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$4.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1.98
|
| Rate for Payer: United Healthcare Commercial |
$4.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.98
|
| Rate for Payer: United Healthcare VA CCN |
$1.98
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 6586284601
|
| Hospital Charge Code |
2500000589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna of VT Commercial |
$4.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3.51
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3.51
|
| Rate for Payer: Multiplan Commercial |
$4.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3.73
|
| Rate for Payer: United Healthcare Commercial |
$4.17
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840002
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
IP
|
$550.09
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
4502840001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$407.12 |
| Max. Negotiated Rate |
$522.59 |
| Rate for Payer: Aetna of VT Commercial |
$522.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$407.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$407.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$467.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$462.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$440.07
|
| Rate for Payer: Cash Price |
$275.04
|
| Rate for Payer: Cigna Commercial |
$440.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$440.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$440.07
|
| Rate for Payer: Multiplan Commercial |
$511.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$467.58
|
| Rate for Payer: United Healthcare Commercial |
$522.59
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Professional
|
Both
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840002
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840002
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
9812840001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$460.63 |
| Rate for Payer: Aetna of VT Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| 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 |
$0.90
|
| 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 |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| 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 |
$0.93
|
| 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
|
|
|
CLSD TX CALCANEAL FX W/O MANIP
|
Facility
|
OP
|
$550.09
|
|
|
Service Code
|
CPT 28400
|
| Hospital Charge Code |
4502840001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$243.63 |
| Max. Negotiated Rate |
$522.59 |
| Rate for Payer: Aetna of VT Commercial |
$522.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$492.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$243.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$492.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$331.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$467.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$445.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$247.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$437.32
|
| Rate for Payer: Cash Price |
$275.04
|
| Rate for Payer: Cigna Commercial |
$440.07
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$440.07
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$440.07
|
| Rate for Payer: Martins Point Health Care Commercial |
$247.54
|
| Rate for Payer: Multiplan Commercial |
$511.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$467.58
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$247.54
|
| Rate for Payer: United Healthcare Commercial |
$522.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$247.54
|
| Rate for Payer: United Healthcare VA CCN |
$247.54
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
OP
|
$129.25
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
4502843001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$57.24 |
| Max. Negotiated Rate |
$122.79 |
| Rate for Payer: Aetna of VT Commercial |
$122.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$115.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$115.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$109.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$104.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$102.75
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cigna Commercial |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$103.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$58.16
|
| Rate for Payer: Multiplan Commercial |
$120.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$109.86
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$58.16
|
| Rate for Payer: United Healthcare Commercial |
$122.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$58.16
|
| Rate for Payer: United Healthcare VA CCN |
$58.16
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9812843001
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of VT Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.80
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna Commercial |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.45
|
| Rate for Payer: United Healthcare VA CCN |
$0.45
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
9812843002
|
|
Hospital Revenue Code
|
981
|
| 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
|
|
|
CLSD TX TALUS FX W/O MANIP
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
CPT 28430
|
| Hospital Charge Code |
4502843001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$95.66 |
| Max. Negotiated Rate |
$122.79 |
| Rate for Payer: Aetna of VT Commercial |
$122.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$95.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$95.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$109.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$108.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$103.40
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cigna Commercial |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$103.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$103.40
|
| Rate for Payer: Multiplan Commercial |
$120.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$109.86
|
| Rate for Payer: United Healthcare Commercial |
$122.79
|
|
