|
MM MAMMO SCR INCL CAD UNILAT
|
Facility
|
IP
|
$523.20
|
|
|
Service Code
|
CPT 77067 52|LT
|
| Hospital Charge Code |
40377067LT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$387.22 |
| Max. Negotiated Rate |
$497.04 |
| Rate for Payer: Aetna of VT Commercial |
$497.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$444.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$439.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$418.56
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$418.56
|
| Rate for Payer: Multiplan Commercial |
$486.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$444.72
|
| Rate for Payer: United Healthcare Commercial |
$497.04
|
|
|
MM MAMMO SCR INCL CAD UNILAT
|
Facility
|
OP
|
$523.20
|
|
|
Service Code
|
CPT 77067 52|RT
|
| Hospital Charge Code |
40377067RT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$231.73 |
| Max. Negotiated Rate |
$497.04 |
| Rate for Payer: Aetna of VT Commercial |
$497.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$400.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$231.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$400.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$314.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$444.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$423.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$235.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$415.94
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$418.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$235.44
|
| Rate for Payer: Multiplan Commercial |
$486.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$444.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$235.44
|
| Rate for Payer: United Healthcare Commercial |
$497.04
|
| Rate for Payer: United Healthcare VA CCN |
$235.44
|
|
|
MM MAMMO SCR INCL CAD UNILAT
|
Facility
|
IP
|
$523.20
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
4037706702
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$387.22 |
| Max. Negotiated Rate |
$497.04 |
| Rate for Payer: Aetna of VT Commercial |
$497.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$387.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$387.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$444.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$439.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$418.56
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cigna Commercial |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$418.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$418.56
|
| Rate for Payer: Multiplan Commercial |
$486.58
|
| Rate for Payer: MVP Health Care of NY Commercial |
$444.72
|
| Rate for Payer: United Healthcare Commercial |
$497.04
|
|
|
MM MAMMO SCRN TOMO BILAT
|
Facility
|
OP
|
$65.76
|
|
|
Service Code
|
CPT 77063
|
| Hospital Charge Code |
4037706301
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$29.13 |
| Max. Negotiated Rate |
$104.04 |
| Rate for Payer: Aetna of VT Commercial |
$62.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$29.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$39.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$55.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$53.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$29.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$52.28
|
| Rate for Payer: Cash Price |
$32.88
|
| Rate for Payer: Cash Price |
$32.88
|
| Rate for Payer: Cigna Commercial |
$52.61
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$52.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$52.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$29.59
|
| Rate for Payer: Multiplan Commercial |
$61.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$29.59
|
| Rate for Payer: United Healthcare Commercial |
$62.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.10
|
| Rate for Payer: United Healthcare VA CCN |
$29.59
|
|
|
MM MAMMO SCRN TOMO BILAT
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 77063 26
|
| Hospital Charge Code |
9727706301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$31.89 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Aetna of VT Commercial |
$68.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$31.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$43.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$61.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$58.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$32.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$57.24
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$57.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$57.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$57.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$32.40
|
| Rate for Payer: Multiplan Commercial |
$66.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.20
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$32.40
|
| Rate for Payer: United Healthcare Commercial |
$68.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.40
|
| Rate for Payer: United Healthcare VA CCN |
$32.40
|
|
|
MM MAMMO SCRN TOMO BILAT
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
CPT 77063 26
|
| Hospital Charge Code |
9727706301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$104.04 |
| Rate for Payer: Aetna of VT Commercial |
$67.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$27.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$37.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$41.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$31.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$41.53
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$40.49
|
| Rate for Payer: Martins Point Health Care Commercial |
$26.97
|
| Rate for Payer: Multiplan Commercial |
$66.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$38.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$26.98
|
| Rate for Payer: United Healthcare Commercial |
$41.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.98
|
| Rate for Payer: United Healthcare VA CCN |
$26.98
|
|
|
MM MAMMO SCRN TOMO BILAT
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 77063 26
|
| Hospital Charge Code |
9727706301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$53.29 |
| Max. Negotiated Rate |
$68.40 |
| Rate for Payer: Aetna of VT Commercial |
$68.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$53.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$53.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$61.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$60.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$57.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$57.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$57.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$66.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$61.20
|
| Rate for Payer: United Healthcare Commercial |
$68.40
|
|
|
MM MAMMO SCRN TOMO BILAT
|
Facility
|
IP
|
$65.76
|
|
|
Service Code
|
CPT 77063
|
| Hospital Charge Code |
4037706301
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$48.67 |
| Max. Negotiated Rate |
$62.47 |
| Rate for Payer: Aetna of VT Commercial |
$62.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$48.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$48.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$55.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$55.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$52.61
|
| Rate for Payer: Cash Price |
$32.88
|
| Rate for Payer: Cigna Commercial |
$52.61
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$52.61
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$52.61
|
| Rate for Payer: Multiplan Commercial |
$61.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$55.90
|
| Rate for Payer: United Healthcare Commercial |
$62.47
|
|
|
MM MAMMO SCRN TOMO UNILAT
|
Facility
|
IP
|
$119.94
|
|
|
Service Code
|
CPT 77063 52|RT
|
| Hospital Charge Code |
40377063RT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$88.77 |
| Max. Negotiated Rate |
$113.94 |
| Rate for Payer: Aetna of VT Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.95
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.95
|
| Rate for Payer: Multiplan Commercial |
$111.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.95
|
| Rate for Payer: United Healthcare Commercial |
$113.94
|
|
|
MM MAMMO SCRN TOMO UNILAT
|
Facility
|
OP
|
$119.94
|
|
|
Service Code
|
CPT 77063 52|RT
|
| Hospital Charge Code |
40377063RT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$53.12 |
| Max. Negotiated Rate |
$113.94 |
| Rate for Payer: Aetna of VT Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$97.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.35
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.95
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.97
|
| Rate for Payer: Multiplan Commercial |
$111.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.97
|
| Rate for Payer: United Healthcare Commercial |
$113.94
|
| Rate for Payer: United Healthcare VA CCN |
$53.97
|
|
|
MM MAMMO SCRN TOMO UNILAT
|
Facility
|
IP
|
$119.94
|
|
|
Service Code
|
CPT 77063 52|LT
|
| Hospital Charge Code |
40377063LT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$88.77 |
| Max. Negotiated Rate |
$113.94 |
| Rate for Payer: Aetna of VT Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.95
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.95
|
| Rate for Payer: Multiplan Commercial |
$111.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.95
|
| Rate for Payer: United Healthcare Commercial |
$113.94
|
|
|
MM MAMMO SCRN TOMO UNILAT
|
Facility
|
OP
|
$119.94
|
|
|
Service Code
|
CPT 77063 52|LT
|
| Hospital Charge Code |
40377063LT
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$53.12 |
| Max. Negotiated Rate |
$113.94 |
| Rate for Payer: Aetna of VT Commercial |
$113.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$101.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$97.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$53.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.35
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$95.95
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$95.95
|
| Rate for Payer: Martins Point Health Care Commercial |
$53.97
|
| Rate for Payer: Multiplan Commercial |
$111.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$101.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$53.97
|
| Rate for Payer: United Healthcare Commercial |
$113.94
|
| Rate for Payer: United Healthcare VA CCN |
$53.97
|
|
|
MM PERQ DVC BREAST LOC 1ST LES
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 19281 26
|
| Hospital Charge Code |
9721928101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$295.86 |
| Max. Negotiated Rate |
$634.60 |
| Rate for Payer: Aetna of VT Commercial |
$634.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$598.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$295.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$598.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$402.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$567.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$541.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$300.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$531.06
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$534.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$534.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$534.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$300.60
|
| Rate for Payer: Multiplan Commercial |
$621.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$567.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$300.60
|
| Rate for Payer: United Healthcare Commercial |
$634.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$300.60
|
| Rate for Payer: United Healthcare VA CCN |
$300.60
|
|
|
MM PERQ DVC BREAST LOC 1ST LES
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
CPT 19281 26
|
| Hospital Charge Code |
9721928101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$149.15 |
| Max. Negotiated Rate |
$627.92 |
| Rate for Payer: Aetna of VT Commercial |
$627.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$598.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$598.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$340.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$340.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$340.52
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$166.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$149.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$149.15
|
| Rate for Payer: Martins Point Health Care Commercial |
$228.14
|
| Rate for Payer: Multiplan Commercial |
$621.24
|
| Rate for Payer: United Healthcare Commercial |
$567.80
|
| Rate for Payer: United Healthcare VA CCN |
$267.20
|
|
|
MM PERQ DVC BREAST LOC 1ST LES
|
Facility
|
IP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281
|
| Hospital Charge Code |
4011928101
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$3,018.20 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.48
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
|
|
MM PERQ DVC BREAST LOC 1ST LES
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 19281 26
|
| Hospital Charge Code |
9721928101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$494.39 |
| Max. Negotiated Rate |
$634.60 |
| Rate for Payer: Aetna of VT Commercial |
$634.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$494.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$494.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$567.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$561.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$534.40
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$534.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$534.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$534.40
|
| Rate for Payer: Multiplan Commercial |
$621.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$567.80
|
| Rate for Payer: United Healthcare Commercial |
$634.60
|
|
|
MM PERQ DVC BREAST LOC 1ST LES
|
Facility
|
OP
|
$4,078.10
|
|
|
Service Code
|
CPT 19281
|
| Hospital Charge Code |
4011928101
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$1,806.19 |
| Max. Negotiated Rate |
$3,874.20 |
| Rate for Payer: Aetna of VT Commercial |
$3,874.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,653.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,455.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,242.09
|
| Rate for Payer: Cash Price |
$2,039.05
|
| Rate for Payer: Cigna Commercial |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.48
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.14
|
| Rate for Payer: Multiplan Commercial |
$3,792.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.39
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare Commercial |
$3,874.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.14
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.14
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
IP
|
$252.30
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
4010027901
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$186.73 |
| Max. Negotiated Rate |
$239.69 |
| Rate for Payer: Aetna of VT Commercial |
$239.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$186.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$186.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$214.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$211.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$201.84
|
| Rate for Payer: Cash Price |
$126.15
|
| Rate for Payer: Cigna Commercial |
$201.84
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$201.84
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$201.84
|
| Rate for Payer: Multiplan Commercial |
$234.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$214.46
|
| Rate for Payer: United Healthcare Commercial |
$239.69
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
OP
|
$66.95
|
|
|
Service Code
|
HCPCS G0279 RT
|
| Hospital Charge Code |
401G0279RT
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.65 |
| Max. Negotiated Rate |
$83.81 |
| Rate for Payer: Aetna of VT Commercial |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$29.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$40.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$54.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$30.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$53.23
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cigna Commercial |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$30.13
|
| Rate for Payer: Multiplan Commercial |
$62.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$30.13
|
| Rate for Payer: United Healthcare Commercial |
$63.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.13
|
| Rate for Payer: United Healthcare VA CCN |
$30.13
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
IP
|
$66.95
|
|
|
Service Code
|
HCPCS G0279 LT
|
| Hospital Charge Code |
401G0279LT
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$63.60 |
| Rate for Payer: Aetna of VT Commercial |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$49.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$49.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$56.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$53.56
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cigna Commercial |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$62.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.91
|
| Rate for Payer: United Healthcare Commercial |
$63.60
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
IP
|
$66.95
|
|
|
Service Code
|
HCPCS G0279 RT
|
| Hospital Charge Code |
401G0279RT
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$63.60 |
| Rate for Payer: Aetna of VT Commercial |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$49.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$49.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$56.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$53.56
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cigna Commercial |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$62.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.91
|
| Rate for Payer: United Healthcare Commercial |
$63.60
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
9720027901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$99.17 |
| Max. Negotiated Rate |
$127.30 |
| Rate for Payer: Aetna of VT Commercial |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$99.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$99.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$112.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$107.20
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$107.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$107.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$107.20
|
| Rate for Payer: Multiplan Commercial |
$124.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$113.90
|
| Rate for Payer: United Healthcare Commercial |
$127.30
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Professional
|
Both
|
$134.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
9720027901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.46 |
| Max. Negotiated Rate |
$125.96 |
| Rate for Payer: Aetna of VT Commercial |
$125.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$43.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$58.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$76.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$76.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$48.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$76.74
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$34.46
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$34.46
|
| Rate for Payer: Martins Point Health Care Commercial |
$42.08
|
| Rate for Payer: Multiplan Commercial |
$124.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$59.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$42.07
|
| Rate for Payer: United Healthcare Commercial |
$64.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.07
|
| Rate for Payer: United Healthcare VA CCN |
$42.07
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
OP
|
$66.95
|
|
|
Service Code
|
HCPCS G0279 LT
|
| Hospital Charge Code |
401G0279LT
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.65 |
| Max. Negotiated Rate |
$83.81 |
| Rate for Payer: Aetna of VT Commercial |
$63.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$29.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$40.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$54.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$30.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$53.23
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Cigna Commercial |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$53.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$53.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$30.13
|
| Rate for Payer: Multiplan Commercial |
$62.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$56.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$30.13
|
| Rate for Payer: United Healthcare Commercial |
$63.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.13
|
| Rate for Payer: United Healthcare VA CCN |
$30.13
|
|
|
MM TOMO MAMMO DX UNILAT/BILAT
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
9720027901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$59.35 |
| Max. Negotiated Rate |
$127.30 |
| Rate for Payer: Aetna of VT Commercial |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$120.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$59.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$120.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$80.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$113.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$108.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$60.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.53
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$107.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$107.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$107.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.30
|
| Rate for Payer: Multiplan Commercial |
$124.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$113.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.30
|
| Rate for Payer: United Healthcare Commercial |
$127.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.30
|
| Rate for Payer: United Healthcare VA CCN |
$60.30
|
|
