|
CT LUMBAR SPINE W/O & W/CONTR
|
Professional
|
Both
|
$184.00
|
|
|
Service Code
|
CPT 72133 26
|
| Hospital Charge Code |
9727213301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$56.54 |
| Max. Negotiated Rate |
$622.37 |
| Rate for Payer: Aetna of VT Commercial |
$172.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$622.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$622.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$91.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$91.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$65.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$89.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$56.54
|
| Rate for Payer: Multiplan Commercial |
$171.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$56.54
|
| Rate for Payer: United Healthcare Commercial |
$86.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.54
|
| Rate for Payer: United Healthcare VA CCN |
$56.54
|
|
|
CT LUMBAR SPINE W/O & W/CONTR
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 72133 26
|
| Hospital Charge Code |
9727213301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$81.49 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna of VT Commercial |
$174.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$81.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$164.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$110.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$156.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$149.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$82.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$146.28
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$147.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$147.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$171.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$156.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$82.80
|
| Rate for Payer: United Healthcare Commercial |
$174.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.80
|
| Rate for Payer: United Healthcare VA CCN |
$82.80
|
|
|
CT LUMBAR SPINE W/O & W/CONTR
|
Facility
|
IP
|
$3,496.37
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
3527213301
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,587.66 |
| Max. Negotiated Rate |
$3,321.55 |
| Rate for Payer: Aetna of VT Commercial |
$3,321.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,587.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,587.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,971.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,936.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,797.10
|
| Rate for Payer: Cash Price |
$1,748.18
|
| Rate for Payer: Cigna Commercial |
$2,797.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,797.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,797.10
|
| Rate for Payer: Multiplan Commercial |
$3,251.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,971.91
|
| Rate for Payer: United Healthcare Commercial |
$3,321.55
|
|
|
CT LUMBAR SPINE W/O & W/CONTR
|
Facility
|
OP
|
$3,496.37
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
3527213301
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$622.37 |
| Max. Negotiated Rate |
$3,321.55 |
| Rate for Payer: Aetna of VT Commercial |
$3,321.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$622.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,548.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$622.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,104.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,971.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,832.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,573.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,779.61
|
| Rate for Payer: Cash Price |
$1,748.18
|
| Rate for Payer: Cash Price |
$1,748.18
|
| Rate for Payer: Cigna Commercial |
$2,797.10
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,797.10
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,797.10
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,573.37
|
| Rate for Payer: Multiplan Commercial |
$3,251.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,971.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,573.37
|
| Rate for Payer: United Healthcare Commercial |
$3,321.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,573.37
|
| Rate for Payer: United Healthcare VA CCN |
$1,573.37
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 70487 26
|
| Hospital Charge Code |
9727048701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$173.92 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna of VT Commercial |
$223.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$173.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$173.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$199.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$197.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$188.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.00
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.75
|
| Rate for Payer: United Healthcare Commercial |
$223.25
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 70487 26
|
| Hospital Charge Code |
9727048701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna of VT Commercial |
$223.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$210.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$104.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$210.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$141.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$199.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$190.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$186.82
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.75
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$105.75
|
| Rate for Payer: United Healthcare Commercial |
$223.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.75
|
| Rate for Payer: United Healthcare VA CCN |
$105.75
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
OP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487 LT
|
| Hospital Charge Code |
35170487LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$447.53 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,092.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,484.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,997.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,109.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,960.54
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,109.74
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare VA CCN |
$1,109.74
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
OP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487 RT
|
| Hospital Charge Code |
35170487RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$447.53 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,092.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,484.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,997.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,109.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,960.54
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,109.74
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare VA CCN |
$1,109.74
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
OP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
3517048704
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$447.53 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,092.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,484.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,997.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,109.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,960.54
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,109.74
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,109.74
|
| Rate for Payer: United Healthcare VA CCN |
$1,109.74
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
IP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
3517048704
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,825.15 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,071.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,972.87
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
IP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487 RT
|
| Hospital Charge Code |
35170487RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,825.15 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,071.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,972.87
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Facility
|
IP
|
$2,466.09
|
|
|
Service Code
|
CPT 70487 LT
|
| Hospital Charge Code |
35170487LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,825.15 |
| Max. Negotiated Rate |
$2,342.79 |
| Rate for Payer: Aetna of VT Commercial |
$2,342.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,825.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,096.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,071.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,972.87
|
| Rate for Payer: Cash Price |
$1,233.05
|
| Rate for Payer: Cigna Commercial |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,972.87
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,972.87
|
| Rate for Payer: Multiplan Commercial |
$2,293.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,096.18
|
| Rate for Payer: United Healthcare Commercial |
$2,342.79
|
|
|
CT MAXILLOFACIAL W/CONTRAST
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
CPT 70487 26
|
| Hospital Charge Code |
9727048701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$447.53 |
| Rate for Payer: Aetna of VT Commercial |
$220.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$52.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$447.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$93.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$93.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$58.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$93.64
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$79.06
|
| Rate for Payer: Martins Point Health Care Commercial |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$50.56
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$50.56
|
| Rate for Payer: United Healthcare Commercial |
$77.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.56
|
| Rate for Payer: United Healthcare VA CCN |
$50.56
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
IP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486 RT
|
| Hospital Charge Code |
35170486RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,495.33 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,697.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,616.35
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
OP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486 LT
|
| Hospital Charge Code |
35170486LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$395.73 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$894.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,216.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,636.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$909.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,606.25
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$909.20
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare VA CCN |
$909.20
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
IP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486 LT
|
| Hospital Charge Code |
35170486LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,495.33 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,697.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,616.35
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
CPT 70486 26
|
| Hospital Charge Code |
9727048601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$38.44 |
| Max. Negotiated Rate |
$395.73 |
| Rate for Payer: Aetna of VT Commercial |
$243.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$53.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$84.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$84.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$44.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$84.13
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$60.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$38.44
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.44
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$38.44
|
| Rate for Payer: United Healthcare Commercial |
$59.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.44
|
| Rate for Payer: United Healthcare VA CCN |
$38.44
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 70486 26
|
| Hospital Charge Code |
9727048601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$114.71 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$114.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$232.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$155.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$209.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$116.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.91
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$116.55
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.55
|
| Rate for Payer: United Healthcare VA CCN |
$116.55
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
OP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
3517048601
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$395.73 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$894.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,216.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,636.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$909.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,606.25
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$909.20
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare VA CCN |
$909.20
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 70486 26
|
| Hospital Charge Code |
9727048601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$191.69 |
| Max. Negotiated Rate |
$246.05 |
| Rate for Payer: Aetna of VT Commercial |
$246.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$220.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$217.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$207.20
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$207.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$207.20
|
| Rate for Payer: Multiplan Commercial |
$240.87
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.15
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
OP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486 RT
|
| Hospital Charge Code |
35170486RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$395.73 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$894.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$395.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,216.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,636.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$909.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,606.25
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Martins Point Health Care Commercial |
$909.20
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$909.20
|
| Rate for Payer: United Healthcare VA CCN |
$909.20
|
|
|
CT MAXILLOFACIAL W/O CONTRAST
|
Facility
|
IP
|
$2,020.44
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
3517048601
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,495.33 |
| Max. Negotiated Rate |
$1,919.42 |
| Rate for Payer: Aetna of VT Commercial |
$1,919.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,495.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,717.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,697.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,616.35
|
| Rate for Payer: Cash Price |
$1,010.22
|
| Rate for Payer: Cigna Commercial |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,616.35
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,616.35
|
| Rate for Payer: Multiplan Commercial |
$1,879.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,717.37
|
| Rate for Payer: United Healthcare Commercial |
$1,919.42
|
|
|
CT MAXILLOFACIAL W/O & W/CONTR
|
Facility
|
IP
|
$2,784.56
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
3517048801
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$2,060.85 |
| Max. Negotiated Rate |
$2,645.33 |
| Rate for Payer: Aetna of VT Commercial |
$2,645.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,060.85
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,060.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,366.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,339.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,227.65
|
| Rate for Payer: Cash Price |
$1,392.28
|
| Rate for Payer: Cigna Commercial |
$2,227.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,227.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,227.65
|
| Rate for Payer: Multiplan Commercial |
$2,589.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,366.88
|
| Rate for Payer: United Healthcare Commercial |
$2,645.33
|
|
|
CT MAXILLOFACIAL W/O & W/CONTR
|
Facility
|
OP
|
$2,784.56
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
3517048801
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$561.69 |
| Max. Negotiated Rate |
$2,645.33 |
| Rate for Payer: Aetna of VT Commercial |
$2,645.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$561.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,233.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$561.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,676.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,366.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,255.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,253.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,213.73
|
| Rate for Payer: Cash Price |
$1,392.28
|
| Rate for Payer: Cash Price |
$1,392.28
|
| Rate for Payer: Cigna Commercial |
$2,227.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,227.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,227.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,253.05
|
| Rate for Payer: Multiplan Commercial |
$2,589.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,366.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,253.05
|
| Rate for Payer: United Healthcare Commercial |
$2,645.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,253.05
|
| Rate for Payer: United Healthcare VA CCN |
$1,253.05
|
|
|
CT MAXILLOFACIAL W/O & W/CONTR
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
CPT 70488 26
|
| Hospital Charge Code |
9727048801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$188.73 |
| Max. Negotiated Rate |
$242.25 |
| Rate for Payer: Aetna of VT Commercial |
$242.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$188.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$188.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$204.00
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$204.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$204.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$237.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$216.75
|
| Rate for Payer: United Healthcare Commercial |
$242.25
|
|
