|
MRI LOWER EXTREMITY W/O CONTR
|
Facility
|
IP
|
$3,162.75
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
6107371801
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,340.75 |
| Max. Negotiated Rate |
$3,004.61 |
| Rate for Payer: Aetna of VT Commercial |
$3,004.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,340.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,340.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,688.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,656.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,530.20
|
| Rate for Payer: Cash Price |
$1,581.38
|
| Rate for Payer: Cigna Commercial |
$2,530.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,530.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,530.20
|
| Rate for Payer: Multiplan Commercial |
$2,941.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,688.34
|
| Rate for Payer: United Healthcare Commercial |
$3,004.61
|
|
|
MRI LOWER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$3,162.75
|
|
|
Service Code
|
CPT 73718 LT
|
| Hospital Charge Code |
61073718LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$722.06 |
| Max. Negotiated Rate |
$3,004.61 |
| Rate for Payer: Aetna of VT Commercial |
$3,004.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$722.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,400.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$722.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,903.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,688.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,561.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,423.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,514.39
|
| Rate for Payer: Cash Price |
$1,581.38
|
| Rate for Payer: Cash Price |
$1,581.38
|
| Rate for Payer: Cigna Commercial |
$2,530.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,530.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,530.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,423.24
|
| Rate for Payer: Multiplan Commercial |
$2,941.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,688.34
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,423.24
|
| Rate for Payer: United Healthcare Commercial |
$3,004.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,423.24
|
| Rate for Payer: United Healthcare VA CCN |
$1,423.24
|
|
|
MRI LOWER EXTREMITY W/O CONTR
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 73718 26
|
| Hospital Charge Code |
9727371801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$60.41 |
| Max. Negotiated Rate |
$722.06 |
| Rate for Payer: Aetna of VT Commercial |
$182.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$722.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$722.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$84.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$99.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$99.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$69.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$99.75
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.41
|
| Rate for Payer: Multiplan Commercial |
$180.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$600.00
|
| Rate for Payer: United Healthcare Commercial |
$92.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.41
|
| Rate for Payer: United Healthcare VA CCN |
$60.41
|
|
|
MRI LOWER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 73718 26
|
| Hospital Charge Code |
9727371801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$85.92 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna of VT Commercial |
$184.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$85.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$173.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$116.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$154.23
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$155.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$155.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.30
|
| Rate for Payer: Multiplan Commercial |
$180.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.30
|
| Rate for Payer: United Healthcare Commercial |
$184.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.30
|
| Rate for Payer: United Healthcare VA CCN |
$87.30
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720 RT
|
| Hospital Charge Code |
61073720RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,067.17 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,454.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,241.88
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.03
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.03
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720 LT
|
| Hospital Charge Code |
61073720LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,018.01 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.27
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720 RT
|
| Hospital Charge Code |
61073720RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,018.01 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.27
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
6107372001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,018.01 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,018.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,425.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,262.27
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Professional
|
Both
|
$308.00
|
|
|
Service Code
|
CPT 73720 26
|
| Hospital Charge Code |
9727372001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$96.61 |
| Max. Negotiated Rate |
$1,067.17 |
| Rate for Payer: Aetna of VT Commercial |
$289.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$99.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$135.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$158.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$111.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$158.95
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cigna Commercial |
$150.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$96.61
|
| Rate for Payer: Multiplan Commercial |
$286.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$96.61
|
| Rate for Payer: United Healthcare Commercial |
$148.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$96.61
|
| Rate for Payer: United Healthcare VA CCN |
$96.61
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$308.00
|
|
|
Service Code
|
CPT 73720 26
|
| Hospital Charge Code |
9727372001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$227.95 |
| Max. Negotiated Rate |
$292.60 |
| Rate for Payer: Aetna of VT Commercial |
$292.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$227.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$227.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$258.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$246.40
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cigna Commercial |
$246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$246.40
|
| Rate for Payer: Multiplan Commercial |
$286.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$261.80
|
| Rate for Payer: United Healthcare Commercial |
$292.60
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720 LT
|
| Hospital Charge Code |
61073720LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,067.17 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,454.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,241.88
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.03
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.03
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$308.00
|
|
|
Service Code
|
CPT 73720 26
|
| Hospital Charge Code |
9727372001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$136.41 |
| Max. Negotiated Rate |
$292.60 |
| Rate for Payer: Aetna of VT Commercial |
$292.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$275.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$136.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$275.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$185.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$249.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$138.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$244.86
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cigna Commercial |
$246.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$246.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$246.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$138.60
|
| Rate for Payer: Multiplan Commercial |
$286.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$261.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$292.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$138.60
|
| Rate for Payer: United Healthcare VA CCN |
$138.60
|
|
|
MRI LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,077.84
|
|
|
Service Code
|
CPT 73720
|
| Hospital Charge Code |
6107372001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,067.17 |
| Max. Negotiated Rate |
$3,873.95 |
| Rate for Payer: Aetna of VT Commercial |
$3,873.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,806.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,067.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,454.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,466.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,303.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,835.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,241.88
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cash Price |
$2,038.92
|
| Rate for Payer: Cigna Commercial |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,262.27
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,262.27
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,835.03
|
| Rate for Payer: Multiplan Commercial |
$3,792.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,466.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare Commercial |
$3,873.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,835.03
|
| Rate for Payer: United Healthcare VA CCN |
$1,835.03
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
OP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542 RT
|
| Hospital Charge Code |
61070542RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$867.80 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,534.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,085.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,805.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,558.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,754.02
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,558.88
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare VA CCN |
$1,558.88
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 70542 26
|
| Hospital Charge Code |
9727054201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna of VT Commercial |
$228.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$106.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$215.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$145.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$204.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$195.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$108.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$191.59
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$108.45
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$204.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$108.45
|
| Rate for Payer: United Healthcare Commercial |
$228.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.45
|
| Rate for Payer: United Healthcare VA CCN |
$108.45
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
IP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542 LT
|
| Hospital Charge Code |
61070542LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,563.83 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,909.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
OP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542 LT
|
| Hospital Charge Code |
61070542LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$867.80 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,534.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,085.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,805.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,558.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,754.02
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,558.88
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare VA CCN |
$1,558.88
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
IP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542 RT
|
| Hospital Charge Code |
61070542RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,563.83 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,909.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 70542 26
|
| Hospital Charge Code |
9727054201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$72.53 |
| Max. Negotiated Rate |
$867.80 |
| Rate for Payer: Aetna of VT Commercial |
$226.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$74.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$101.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$116.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$116.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$83.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$116.26
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$113.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$72.53
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$72.53
|
| Rate for Payer: United Healthcare Commercial |
$111.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.53
|
| Rate for Payer: United Healthcare VA CCN |
$72.53
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 70542 26
|
| Hospital Charge Code |
9727054201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna of VT Commercial |
$228.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$178.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$178.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$204.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$202.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$192.80
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cigna Commercial |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$192.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$192.80
|
| Rate for Payer: Multiplan Commercial |
$224.13
|
| Rate for Payer: MVP Health Care of NY Commercial |
$204.85
|
| Rate for Payer: United Healthcare Commercial |
$228.95
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
IP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542
|
| Hospital Charge Code |
6107054201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,563.83 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,563.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,909.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
|
|
MRI ORBIT FACE & NECK W/DYE
|
Facility
|
OP
|
$3,464.17
|
|
|
Service Code
|
CPT 70542
|
| Hospital Charge Code |
6107054201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$867.80 |
| Max. Negotiated Rate |
$3,290.96 |
| Rate for Payer: Aetna of VT Commercial |
$3,290.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,534.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$867.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,085.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,944.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,805.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,558.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,754.02
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cash Price |
$1,732.09
|
| Rate for Payer: Cigna Commercial |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,771.34
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,771.34
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,558.88
|
| Rate for Payer: Multiplan Commercial |
$3,221.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,944.54
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare Commercial |
$3,290.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,558.88
|
| Rate for Payer: United Healthcare VA CCN |
$1,558.88
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
OP
|
$3,054.44
|
|
|
Service Code
|
CPT 70540 RT
|
| Hospital Charge Code |
61070540RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$735.08 |
| Max. Negotiated Rate |
$2,901.72 |
| Rate for Payer: Aetna of VT Commercial |
$2,901.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$735.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,352.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$735.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,838.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,596.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,474.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,374.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,428.28
|
| Rate for Payer: Cash Price |
$1,527.22
|
| Rate for Payer: Cash Price |
$1,527.22
|
| Rate for Payer: Cigna Commercial |
$2,443.55
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,443.55
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,443.55
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,374.50
|
| Rate for Payer: Multiplan Commercial |
$2,840.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,596.27
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,374.50
|
| Rate for Payer: United Healthcare Commercial |
$2,901.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,374.50
|
| Rate for Payer: United Healthcare VA CCN |
$1,374.50
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
CPT 70540 26
|
| Hospital Charge Code |
9727054001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$128.44 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna of VT Commercial |
$275.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$259.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$128.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$259.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$174.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$246.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$234.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$130.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$230.55
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$232.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$232.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$130.50
|
| Rate for Payer: Multiplan Commercial |
$269.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$246.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$130.50
|
| Rate for Payer: United Healthcare Commercial |
$275.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.50
|
| Rate for Payer: United Healthcare VA CCN |
$130.50
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
IP
|
$3,054.44
|
|
|
Service Code
|
CPT 70540 LT
|
| Hospital Charge Code |
61070540LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,260.59 |
| Max. Negotiated Rate |
$2,901.72 |
| Rate for Payer: Aetna of VT Commercial |
$2,901.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,260.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,260.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,596.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,565.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,443.55
|
| Rate for Payer: Cash Price |
$1,527.22
|
| Rate for Payer: Cigna Commercial |
$2,443.55
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,443.55
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,443.55
|
| Rate for Payer: Multiplan Commercial |
$2,840.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,596.27
|
| Rate for Payer: United Healthcare Commercial |
$2,901.72
|
|
