|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
IP
|
$3,054.44
|
|
|
Service Code
|
CPT 70540 RT
|
| Hospital Charge Code |
61070540RT
|
|
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
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
IP
|
$3,054.44
|
|
|
Service Code
|
CPT 70540
|
| Hospital Charge Code |
6107054001
|
|
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
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
CPT 70540 26
|
| Hospital Charge Code |
9727054001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$214.63 |
| 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 |
$214.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$214.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$246.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$243.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$232.00
|
| 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: Multiplan Commercial |
$269.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$246.50
|
| Rate for Payer: United Healthcare Commercial |
$275.50
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
CPT 70540 26
|
| Hospital Charge Code |
9727054001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$60.09 |
| Max. Negotiated Rate |
$735.08 |
| Rate for Payer: Aetna of VT Commercial |
$272.60
|
| 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 |
$61.89
|
| 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 |
$84.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$96.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$69.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.84
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.09
|
| Rate for Payer: Multiplan Commercial |
$269.70
|
| 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 |
$92.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.09
|
| Rate for Payer: United Healthcare VA CCN |
$60.09
|
|
|
MRI ORBIT FACE &/NECK W/O DYE
|
Facility
|
OP
|
$3,054.44
|
|
|
Service Code
|
CPT 70540 LT
|
| Hospital Charge Code |
61070540LT
|
|
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
|
$3,054.44
|
|
|
Service Code
|
CPT 70540
|
| Hospital Charge Code |
6107054001
|
|
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 &W/DYE
|
Facility
|
OP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543 LT
|
| Hospital Charge Code |
61070543LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,074.43 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,746.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,374.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,194.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,774.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,135.23
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,774.66
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare VA CCN |
$1,774.66
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
OP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543
|
| Hospital Charge Code |
6107054301
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,074.43 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,746.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,374.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,194.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,774.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,135.23
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,774.66
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare VA CCN |
$1,774.66
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
IP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543
|
| Hospital Charge Code |
6107054301
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,918.72 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,312.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,154.94
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
IP
|
$384.00
|
|
|
Service Code
|
CPT 70543 26
|
| Hospital Charge Code |
9727054301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$284.20 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna of VT Commercial |
$364.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$284.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$284.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$326.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$322.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$307.20
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$307.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.20
|
| Rate for Payer: Multiplan Commercial |
$357.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$326.40
|
| Rate for Payer: United Healthcare Commercial |
$364.80
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
OP
|
$384.00
|
|
|
Service Code
|
CPT 70543 26
|
| Hospital Charge Code |
9727054301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$170.07 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna of VT Commercial |
$364.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$344.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$170.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$344.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$231.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$326.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$311.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$305.28
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$307.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$307.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$307.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$172.80
|
| Rate for Payer: Multiplan Commercial |
$357.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$326.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$172.80
|
| Rate for Payer: United Healthcare Commercial |
$364.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$172.80
|
| Rate for Payer: United Healthcare VA CCN |
$172.80
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Professional
|
Both
|
$384.00
|
|
|
Service Code
|
CPT 70543 26
|
| Hospital Charge Code |
9727054301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$96.28 |
| Max. Negotiated Rate |
$1,074.43 |
| Rate for Payer: Aetna of VT Commercial |
$360.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$99.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$134.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$154.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$154.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$110.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$154.84
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$150.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$96.28
|
| Rate for Payer: Multiplan Commercial |
$357.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$96.29
|
| Rate for Payer: United Healthcare Commercial |
$148.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$96.29
|
| Rate for Payer: United Healthcare VA CCN |
$96.29
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
OP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543 RT
|
| Hospital Charge Code |
61070543RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,074.43 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,746.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,074.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,374.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,194.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,774.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,135.23
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,774.66
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,774.66
|
| Rate for Payer: United Healthcare VA CCN |
$1,774.66
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
IP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543 RT
|
| Hospital Charge Code |
61070543RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,918.72 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,312.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,154.94
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
|
|
MRI ORBIT/FACE/NECK W/O &W/DYE
|
Facility
|
IP
|
$3,943.68
|
|
|
Service Code
|
CPT 70543 LT
|
| Hospital Charge Code |
61070543LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,918.72 |
| Max. Negotiated Rate |
$3,746.50 |
| Rate for Payer: Aetna of VT Commercial |
$3,746.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,918.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,352.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,312.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,154.94
|
| Rate for Payer: Cash Price |
$1,971.84
|
| Rate for Payer: Cigna Commercial |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,154.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,154.94
|
| Rate for Payer: Multiplan Commercial |
$3,667.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,352.13
|
| Rate for Payer: United Healthcare Commercial |
$3,746.50
|
|
|
MRI PELVIS W/CONTRAST MATERIAL
|
Facility
|
OP
|
$3,430.95
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
6107219601
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$846.12 |
| Max. Negotiated Rate |
$3,259.40 |
| Rate for Payer: Aetna of VT Commercial |
$3,259.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$846.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,519.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$846.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,065.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,916.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,779.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,543.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,727.61
|
| Rate for Payer: Cash Price |
$1,715.47
|
| Rate for Payer: Cash Price |
$1,715.47
|
| Rate for Payer: Cigna Commercial |
$2,744.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,744.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,744.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,543.93
|
| Rate for Payer: Multiplan Commercial |
$3,190.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,916.31
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,543.93
|
| Rate for Payer: United Healthcare Commercial |
$3,259.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,543.93
|
| Rate for Payer: United Healthcare VA CCN |
$1,543.93
|
|
|
MRI PELVIS W/CONTRAST MATERIAL
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 72196 26
|
| Hospital Charge Code |
9727219601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$185.03 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna of VT Commercial |
$237.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$185.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$185.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$210.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$200.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.00
|
| Rate for Payer: Multiplan Commercial |
$232.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$212.50
|
| Rate for Payer: United Healthcare Commercial |
$237.50
|
|
|
MRI PELVIS W/CONTRAST MATERIAL
|
Facility
|
IP
|
$3,430.95
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
6107219601
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,539.25 |
| Max. Negotiated Rate |
$3,259.40 |
| Rate for Payer: Aetna of VT Commercial |
$3,259.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,539.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,539.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,916.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,882.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,744.76
|
| Rate for Payer: Cash Price |
$1,715.47
|
| Rate for Payer: Cigna Commercial |
$2,744.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,744.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,744.76
|
| Rate for Payer: Multiplan Commercial |
$3,190.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,916.31
|
| Rate for Payer: United Healthcare Commercial |
$3,259.40
|
|
|
MRI PELVIS W/CONTRAST MATERIAL
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
CPT 72196 26
|
| Hospital Charge Code |
9727219601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$77.21 |
| Max. Negotiated Rate |
$846.12 |
| Rate for Payer: Aetna of VT Commercial |
$235.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$846.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$79.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$846.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$108.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$124.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$124.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$88.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$124.53
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$121.14
|
| Rate for Payer: Martins Point Health Care Commercial |
$77.21
|
| Rate for Payer: Multiplan Commercial |
$232.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$77.21
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$77.21
|
| Rate for Payer: United Healthcare Commercial |
$118.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.21
|
| Rate for Payer: United Healthcare VA CCN |
$77.21
|
|
|
MRI PELVIS W/CONTRAST MATERIAL
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 72196 26
|
| Hospital Charge Code |
9727219601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$110.72 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna of VT Commercial |
$237.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$223.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$110.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$223.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$212.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$202.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$198.75
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$200.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$200.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$200.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$232.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$212.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$237.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$112.50
|
| Rate for Payer: United Healthcare VA CCN |
$112.50
|
|
|
MRI PELVIS W/O CONTRAST
|
Facility
|
OP
|
$3,083.39
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
6107219501
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$723.51 |
| Max. Negotiated Rate |
$2,929.22 |
| Rate for Payer: Aetna of VT Commercial |
$2,929.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$723.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,365.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$723.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,856.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,620.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,497.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,387.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,451.30
|
| Rate for Payer: Cash Price |
$1,541.69
|
| Rate for Payer: Cash Price |
$1,541.69
|
| Rate for Payer: Cigna Commercial |
$2,466.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,466.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,466.71
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,387.53
|
| Rate for Payer: Multiplan Commercial |
$2,867.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,620.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,387.53
|
| Rate for Payer: United Healthcare Commercial |
$2,929.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,387.53
|
| Rate for Payer: United Healthcare VA CCN |
$1,387.53
|
|
|
MRI PELVIS W/O CONTRAST
|
Facility
|
IP
|
$3,083.39
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
6107219501
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,282.02 |
| Max. Negotiated Rate |
$2,929.22 |
| Rate for Payer: Aetna of VT Commercial |
$2,929.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,282.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,282.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,620.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,590.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,466.71
|
| Rate for Payer: Cash Price |
$1,541.69
|
| Rate for Payer: Cigna Commercial |
$2,466.71
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,466.71
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,466.71
|
| Rate for Payer: Multiplan Commercial |
$2,867.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,620.88
|
| Rate for Payer: United Healthcare Commercial |
$2,929.22
|
|
|
MRI PELVIS W/O CONTRAST READ
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$93.45 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna of VT Commercial |
$200.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$93.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$127.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$179.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$170.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$94.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$167.75
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$94.95
|
| Rate for Payer: Multiplan Commercial |
$196.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$94.95
|
| Rate for Payer: United Healthcare Commercial |
$200.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.95
|
| Rate for Payer: United Healthcare VA CCN |
$94.95
|
|
|
MRI PELVIS W/O CONTRAST READ
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$65.42 |
| Max. Negotiated Rate |
$723.51 |
| Rate for Payer: Aetna of VT Commercial |
$198.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$723.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$67.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$723.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$91.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$105.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$105.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$75.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.10
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$103.03
|
| Rate for Payer: Martins Point Health Care Commercial |
$65.42
|
| Rate for Payer: Multiplan Commercial |
$196.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$65.42
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$600.00
|
| Rate for Payer: United Healthcare Commercial |
$100.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.42
|
| Rate for Payer: United Healthcare VA CCN |
$65.42
|
|
|
MRI PELVIS W/O CONTRAST READ
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$156.16 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna of VT Commercial |
$200.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$156.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$156.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$179.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$177.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$168.80
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$168.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$168.80
|
| Rate for Payer: Multiplan Commercial |
$196.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.35
|
| Rate for Payer: United Healthcare Commercial |
$200.45
|
|
