|
CT MAXILLOFACIAL W/O & W/CONTR
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
CPT 70488 26
|
| Hospital Charge Code |
9727048801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$112.94 |
| 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 |
$228.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$112.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$228.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$153.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$216.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$206.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$114.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$202.72
|
| 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: Martins Point Health Care Commercial |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$237.15
|
| Rate for Payer: MVP Health Care of NY Commercial |
$216.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$114.75
|
| Rate for Payer: United Healthcare Commercial |
$242.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.75
|
| Rate for Payer: United Healthcare VA CCN |
$114.75
|
|
|
CT MAXILLOFACIAL W/O & W/CONTR
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
CPT 70488 26
|
| Hospital Charge Code |
9727048801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$56.54 |
| Max. Negotiated Rate |
$561.69 |
| Rate for Payer: Aetna of VT Commercial |
$239.70
|
| 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 |
$58.24
|
| 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 |
$79.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$104.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$104.70
|
| 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 |
$104.70
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$89.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$56.54
|
| Rate for Payer: Multiplan Commercial |
$237.15
|
| 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 ORBIT/EAR/FOSSA W/DYE
|
Facility
|
IP
|
$2,318.49
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
3517048101
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,715.91 |
| Max. Negotiated Rate |
$2,202.57 |
| Rate for Payer: Aetna of VT Commercial |
$2,202.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,715.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,715.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,970.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,947.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,854.79
|
| Rate for Payer: Cash Price |
$1,159.24
|
| Rate for Payer: Cigna Commercial |
$1,854.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,854.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,854.79
|
| Rate for Payer: Multiplan Commercial |
$2,156.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,970.72
|
| Rate for Payer: United Healthcare Commercial |
$2,202.57
|
|
|
CT ORBIT/EAR/FOSSA W/DYE
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
CPT 70481 26
|
| Hospital Charge Code |
9727048101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$109.84 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Aetna of VT Commercial |
$235.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$222.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$109.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$222.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$149.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$210.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$200.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$111.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$197.16
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cigna Commercial |
$198.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$198.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$198.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$111.60
|
| Rate for Payer: Multiplan Commercial |
$230.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$210.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$111.60
|
| Rate for Payer: United Healthcare Commercial |
$235.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.60
|
| Rate for Payer: United Healthcare VA CCN |
$111.60
|
|
|
CT ORBIT/EAR/FOSSA W/DYE
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
CPT 70481 26
|
| Hospital Charge Code |
9727048101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$183.54 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Aetna of VT Commercial |
$235.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$183.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$183.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$210.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$208.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$198.40
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cigna Commercial |
$198.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$198.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$198.40
|
| Rate for Payer: Multiplan Commercial |
$230.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$210.80
|
| Rate for Payer: United Healthcare Commercial |
$235.60
|
|
|
CT ORBIT/EAR/FOSSA W/DYE
|
Facility
|
OP
|
$2,318.49
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
3517048101
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$573.25 |
| Max. Negotiated Rate |
$2,202.57 |
| Rate for Payer: Aetna of VT Commercial |
$2,202.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$573.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,026.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$573.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,395.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,970.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,877.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,043.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,843.20
|
| Rate for Payer: Cash Price |
$1,159.24
|
| Rate for Payer: Cash Price |
$1,159.24
|
| Rate for Payer: Cigna Commercial |
$1,854.79
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,854.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,854.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,043.32
|
| Rate for Payer: Multiplan Commercial |
$2,156.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,970.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,043.32
|
| Rate for Payer: United Healthcare Commercial |
$2,202.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,043.32
|
| Rate for Payer: United Healthcare VA CCN |
$1,043.32
|
|
|
CT ORBIT/EAR/FOSSA W/DYE
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 70481 26
|
| Hospital Charge Code |
9727048101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$573.25 |
| Rate for Payer: Aetna of VT Commercial |
$233.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$573.25
|
| 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 |
$573.25
|
| 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 |
$101.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$101.93
|
| 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 |
$101.93
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cigna Commercial |
$79.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$50.56
|
| Rate for Payer: Multiplan Commercial |
$230.64
|
| 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 ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 70480 26
|
| Hospital Charge Code |
9727048001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$170.22 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$170.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$193.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$184.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
CPT 70480 26
|
| Hospital Charge Code |
9727048001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$57.51 |
| Max. Negotiated Rate |
$444.63 |
| Rate for Payer: Aetna of VT Commercial |
$216.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$59.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$80.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$66.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$94.81
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$90.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$57.51
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$57.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$57.51
|
| Rate for Payer: United Healthcare Commercial |
$88.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.51
|
| Rate for Payer: United Healthcare VA CCN |
$57.51
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 70480 26
|
| Hospital Charge Code |
9727048001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$101.87 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna of VT Commercial |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$206.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$138.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$195.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.85
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$184.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$184.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$213.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare Commercial |
$218.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.50
|
| Rate for Payer: United Healthcare VA CCN |
$103.50
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
IP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480 LT
|
| Hospital Charge Code |
35170480LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,501.83 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,704.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,623.38
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
OP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480 LT
|
| Hospital Charge Code |
35170480LT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$444.63 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$898.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,221.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,643.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$913.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,613.24
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$913.15
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare VA CCN |
$913.15
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
IP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480 RT
|
| Hospital Charge Code |
35170480RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,501.83 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,704.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,623.38
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
IP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
3517048001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,501.83 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,501.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,704.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,623.38
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
OP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
3517048001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$444.63 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$898.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,221.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,643.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$913.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,613.24
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$913.15
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare VA CCN |
$913.15
|
|
|
CT ORBIT/EAR/FOSSA W/O DYE
|
Facility
|
OP
|
$2,029.23
|
|
|
Service Code
|
CPT 70480 RT
|
| Hospital Charge Code |
35170480RT
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$444.63 |
| Max. Negotiated Rate |
$1,927.77 |
| Rate for Payer: Aetna of VT Commercial |
$1,927.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$898.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$444.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,221.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,724.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,643.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$913.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,613.24
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cash Price |
$1,014.62
|
| Rate for Payer: Cigna Commercial |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,623.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,623.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$913.15
|
| Rate for Payer: Multiplan Commercial |
$1,887.18
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,724.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare Commercial |
$1,927.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$913.15
|
| Rate for Payer: United Healthcare VA CCN |
$913.15
|
|
|
CT ORBIT/EAR/FOSSA W/O&W/DYE
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 70482 26
|
| Hospital Charge Code |
9727048201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Aetna of VT Commercial |
$247.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$232.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$115.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$232.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$221.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$210.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$117.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$206.70
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$208.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$208.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$208.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$241.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$221.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$117.00
|
| Rate for Payer: United Healthcare Commercial |
$247.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$117.00
|
| Rate for Payer: United Healthcare VA CCN |
$117.00
|
|
|
CT ORBIT/EAR/FOSSA W/O&W/DYE
|
Facility
|
OP
|
$2,762.74
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
3517048201
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$680.15 |
| Max. Negotiated Rate |
$2,624.60 |
| Rate for Payer: Aetna of VT Commercial |
$2,624.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$680.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,223.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$680.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,663.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,348.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,237.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,243.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,196.38
|
| Rate for Payer: Cash Price |
$1,381.37
|
| Rate for Payer: Cash Price |
$1,381.37
|
| Rate for Payer: Cigna Commercial |
$2,210.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,210.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,210.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,243.23
|
| Rate for Payer: Multiplan Commercial |
$2,569.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,348.33
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,243.23
|
| Rate for Payer: United Healthcare Commercial |
$2,624.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,243.23
|
| Rate for Payer: United Healthcare VA CCN |
$1,243.23
|
|
|
CT ORBIT/EAR/FOSSA W/O&W/DYE
|
Facility
|
IP
|
$2,762.74
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
3517048201
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$2,044.70 |
| Max. Negotiated Rate |
$2,624.60 |
| Rate for Payer: Aetna of VT Commercial |
$2,624.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,044.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,044.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,348.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,320.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,210.19
|
| Rate for Payer: Cash Price |
$1,381.37
|
| Rate for Payer: Cigna Commercial |
$2,210.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,210.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,210.19
|
| Rate for Payer: Multiplan Commercial |
$2,569.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,348.33
|
| Rate for Payer: United Healthcare Commercial |
$2,624.60
|
|
|
CT ORBIT/EAR/FOSSA W/O&W/DYE
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
CPT 70482 26
|
| Hospital Charge Code |
9727048201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$56.54 |
| Max. Negotiated Rate |
$680.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$680.15
|
| 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 |
$680.15
|
| 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 |
$107.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.41
|
| 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 |
$107.41
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$89.01
|
| Rate for Payer: Martins Point Health Care Commercial |
$56.54
|
| Rate for Payer: Multiplan Commercial |
$241.80
|
| 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 ORBIT/EAR/FOSSA W/O&W/DYE
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 70482 26
|
| Hospital Charge Code |
9727048201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$192.43 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Aetna of VT Commercial |
$247.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$192.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$192.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$221.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$218.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$208.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$208.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$208.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$208.00
|
| Rate for Payer: Multiplan Commercial |
$241.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$221.00
|
| Rate for Payer: United Healthcare Commercial |
$247.00
|
|
|
CT PELVIS W/CONTRAST
|
Professional
|
Both
|
$167.00
|
|
|
Service Code
|
CPT 72193 26
|
| Hospital Charge Code |
9727219301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$772.63 |
| Rate for Payer: Aetna of VT Commercial |
$156.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$772.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$772.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$87.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$87.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$87.28
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$81.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.85
|
| Rate for Payer: Multiplan Commercial |
$155.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.85
|
| Rate for Payer: United Healthcare Commercial |
$79.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.85
|
| Rate for Payer: United Healthcare VA CCN |
$51.85
|
|
|
CT PELVIS W/CONTRAST
|
Facility
|
OP
|
$2,390.61
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
3527219301
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$772.63 |
| Max. Negotiated Rate |
$2,271.08 |
| Rate for Payer: Aetna of VT Commercial |
$2,271.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$772.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,058.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$772.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,439.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,032.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,936.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,075.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,900.53
|
| Rate for Payer: Cash Price |
$1,195.31
|
| Rate for Payer: Cash Price |
$1,195.31
|
| Rate for Payer: Cigna Commercial |
$1,912.49
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,912.49
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,912.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,075.77
|
| Rate for Payer: Multiplan Commercial |
$2,223.27
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,032.02
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,075.77
|
| Rate for Payer: United Healthcare Commercial |
$2,271.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,075.77
|
| Rate for Payer: United Healthcare VA CCN |
$1,075.77
|
|
|
CT PELVIS W/CONTRAST
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT 72193 26
|
| Hospital Charge Code |
9727219301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$73.96 |
| Max. Negotiated Rate |
$158.65 |
| Rate for Payer: Aetna of VT Commercial |
$158.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$149.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$149.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$100.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$135.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$75.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$132.76
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$133.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$133.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$133.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$75.15
|
| Rate for Payer: Multiplan Commercial |
$155.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$75.15
|
| Rate for Payer: United Healthcare Commercial |
$158.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.15
|
| Rate for Payer: United Healthcare VA CCN |
$75.15
|
|
|
CT PELVIS W/CONTRAST
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT 72193 26
|
| Hospital Charge Code |
9727219301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$123.60 |
| Max. Negotiated Rate |
$158.65 |
| Rate for Payer: Aetna of VT Commercial |
$158.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$123.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$123.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$141.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$140.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$133.60
|
| Rate for Payer: Cash Price |
$83.50
|
| Rate for Payer: Cigna Commercial |
$133.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$133.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$133.60
|
| Rate for Payer: Multiplan Commercial |
$155.31
|
| Rate for Payer: MVP Health Care of NY Commercial |
$141.95
|
| Rate for Payer: United Healthcare Commercial |
$158.65
|
|
