|
MRI PELVIS W/O & W/CONTRAST
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$233.13 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna of VT Commercial |
$299.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$267.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$264.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$252.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.00
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.75
|
| Rate for Payer: United Healthcare Commercial |
$299.25
|
|
|
MRI PELVIS W/O & W/CONTRAST
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$139.51 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna of VT Commercial |
$299.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$282.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$139.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$282.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$189.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$267.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$255.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$250.43
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$141.75
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.75
|
| Rate for Payer: United Healthcare Commercial |
$299.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.75
|
| Rate for Payer: United Healthcare VA CCN |
$141.75
|
|
|
MRI PELVIS W/O & W/CONTRAST
|
Facility
|
OP
|
$4,237.33
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
6107219701
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,055.61 |
| Max. Negotiated Rate |
$4,025.46 |
| Rate for Payer: Aetna of VT Commercial |
$4,025.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,876.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,550.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,601.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,432.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,906.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,368.68
|
| Rate for Payer: Cash Price |
$2,118.66
|
| Rate for Payer: Cash Price |
$2,118.66
|
| Rate for Payer: Cigna Commercial |
$3,389.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,389.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,389.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,906.80
|
| Rate for Payer: Multiplan Commercial |
$3,940.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,601.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,906.80
|
| Rate for Payer: United Healthcare Commercial |
$4,025.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,906.80
|
| Rate for Payer: United Healthcare VA CCN |
$1,906.80
|
|
|
MRI PELVIS W/O & W/CONTRAST
|
Facility
|
IP
|
$4,237.33
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
6107219701
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,136.05 |
| Max. Negotiated Rate |
$4,025.46 |
| Rate for Payer: Aetna of VT Commercial |
$4,025.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,136.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,136.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,601.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,559.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,389.86
|
| Rate for Payer: Cash Price |
$2,118.66
|
| Rate for Payer: Cigna Commercial |
$3,389.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,389.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,389.86
|
| Rate for Payer: Multiplan Commercial |
$3,940.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,601.73
|
| Rate for Payer: United Healthcare Commercial |
$4,025.46
|
|
|
MRI PELVIS W/O & W/CONTRAST
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$98.55 |
| Max. Negotiated Rate |
$1,055.61 |
| Rate for Payer: Aetna of VT Commercial |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$113.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.29
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$154.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$98.55
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$98.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare Commercial |
$151.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare VA CCN |
$98.55
|
|
|
MRI SI JOINT WO/W CONTRAS READ
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219702
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$98.55 |
| Max. Negotiated Rate |
$1,055.61 |
| Rate for Payer: Aetna of VT Commercial |
$296.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,055.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$137.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$113.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$162.29
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$154.29
|
| Rate for Payer: Martins Point Health Care Commercial |
$98.55
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$98.55
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare Commercial |
$151.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$98.55
|
| Rate for Payer: United Healthcare VA CCN |
$98.55
|
|
|
MRI SI JOINT WO/W CONTRAS READ
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219702
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$233.13 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna of VT Commercial |
$299.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$267.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$264.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$252.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.00
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.75
|
| Rate for Payer: United Healthcare Commercial |
$299.25
|
|
|
MRI SI JOINT WO/W CONTRAS READ
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
CPT 72197 26
|
| Hospital Charge Code |
9727219702
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$139.51 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna of VT Commercial |
$299.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$282.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$139.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$282.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$189.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$267.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$255.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$250.43
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$252.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$252.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$141.75
|
| Rate for Payer: Multiplan Commercial |
$292.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$267.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.75
|
| Rate for Payer: United Healthcare Commercial |
$299.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.75
|
| Rate for Payer: United Healthcare VA CCN |
$141.75
|
|
|
MRI SPINAL CANAL LUMBAR W/DYE
|
Professional
|
Both
|
$257.00
|
|
|
Service Code
|
CPT 72149 26
|
| Hospital Charge Code |
9727214901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$80.13 |
| Max. Negotiated Rate |
$843.22 |
| Rate for Payer: Aetna of VT Commercial |
$241.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$843.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$843.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$112.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$128.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$92.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$128.75
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$125.48
|
| Rate for Payer: Martins Point Health Care Commercial |
$80.13
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$80.13
|
| Rate for Payer: United Healthcare Commercial |
$123.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$80.13
|
| Rate for Payer: United Healthcare VA CCN |
$80.13
|
|
|
MRI SPINAL CANAL LUMBAR W/DYE
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
CPT 72149 26
|
| Hospital Charge Code |
9727214901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$113.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$154.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$208.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$115.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$204.31
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$115.65
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare VA CCN |
$115.65
|
|
|
MRI SPINAL CANAL LUMBAR W/DYE
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
CPT 72149 26
|
| Hospital Charge Code |
9727214901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$190.21 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.60
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
|
|
MRI SPINAL CANAL LUMBAR W/DYE
|
Facility
|
OP
|
$3,425.64
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
6127214901
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$843.22 |
| Max. Negotiated Rate |
$3,254.36 |
| Rate for Payer: Aetna of VT Commercial |
$3,254.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$843.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,517.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$843.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,062.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,911.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,774.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,541.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,723.38
|
| Rate for Payer: Cash Price |
$1,712.82
|
| Rate for Payer: Cash Price |
$1,712.82
|
| Rate for Payer: Cigna Commercial |
$2,740.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,740.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,740.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,541.54
|
| Rate for Payer: Multiplan Commercial |
$3,185.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,911.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,541.54
|
| Rate for Payer: United Healthcare Commercial |
$3,254.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,541.54
|
| Rate for Payer: United Healthcare VA CCN |
$1,541.54
|
|
|
MRI SPINAL CANAL LUMBAR W/DYE
|
Facility
|
IP
|
$3,425.64
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
6127214901
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,535.32 |
| Max. Negotiated Rate |
$3,254.36 |
| Rate for Payer: Aetna of VT Commercial |
$3,254.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,535.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,535.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,911.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,877.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,740.51
|
| Rate for Payer: Cash Price |
$1,712.82
|
| Rate for Payer: Cigna Commercial |
$2,740.51
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,740.51
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,740.51
|
| Rate for Payer: Multiplan Commercial |
$3,185.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,911.79
|
| Rate for Payer: United Healthcare Commercial |
$3,254.36
|
|
|
MRI SPINAL CANL LUMBAR W/O DYE
|
Facility
|
IP
|
$3,284.24
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
6127214801
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,430.67 |
| Max. Negotiated Rate |
$3,120.03 |
| Rate for Payer: Aetna of VT Commercial |
$3,120.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,430.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,430.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,791.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,758.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,627.39
|
| Rate for Payer: Cash Price |
$1,642.12
|
| Rate for Payer: Cigna Commercial |
$2,627.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,627.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,627.39
|
| Rate for Payer: Multiplan Commercial |
$3,054.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,791.60
|
| Rate for Payer: United Healthcare Commercial |
$3,120.03
|
|
|
MRI SPINAL CANL LUMBAR W/O DYE
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
CPT 72148 26
|
| Hospital Charge Code |
9727214801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$66.39 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of VT Commercial |
$202.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$550.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$68.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$550.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$92.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$106.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$106.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$76.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$106.67
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$104.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$66.39
|
| Rate for Payer: Multiplan Commercial |
$199.95
|
| 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 |
$102.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66.39
|
| Rate for Payer: United Healthcare VA CCN |
$66.39
|
|
|
MRI SPINAL CANL LUMBAR W/O DYE
|
Facility
|
OP
|
$215.00
|
|
|
Service Code
|
CPT 72148 26
|
| Hospital Charge Code |
9727214801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$95.22 |
| Max. Negotiated Rate |
$204.25 |
| Rate for Payer: Aetna of VT Commercial |
$204.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$192.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$95.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$192.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$129.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$182.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$174.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$96.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$170.93
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$172.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$172.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$172.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$199.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$182.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$96.75
|
| Rate for Payer: United Healthcare Commercial |
$204.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$96.75
|
| Rate for Payer: United Healthcare VA CCN |
$96.75
|
|
|
MRI SPINAL CANL LUMBAR W/O DYE
|
Facility
|
IP
|
$215.00
|
|
|
Service Code
|
CPT 72148 26
|
| Hospital Charge Code |
9727214801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$159.12 |
| Max. Negotiated Rate |
$204.25 |
| Rate for Payer: Aetna of VT Commercial |
$204.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$159.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$159.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$182.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$180.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$172.00
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$172.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$172.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$172.00
|
| Rate for Payer: Multiplan Commercial |
$199.95
|
| Rate for Payer: MVP Health Care of NY Commercial |
$182.75
|
| Rate for Payer: United Healthcare Commercial |
$204.25
|
|
|
MRI SPINAL CANL LUMBAR W/O DYE
|
Facility
|
OP
|
$3,284.24
|
|
|
Service Code
|
CPT 72148
|
| Hospital Charge Code |
6127214801
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$550.12 |
| Max. Negotiated Rate |
$3,120.03 |
| Rate for Payer: Aetna of VT Commercial |
$3,120.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$550.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,454.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$550.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,977.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,791.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,660.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,477.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,610.97
|
| Rate for Payer: Cash Price |
$1,642.12
|
| Rate for Payer: Cash Price |
$1,642.12
|
| Rate for Payer: Cigna Commercial |
$2,627.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,627.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,627.39
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,477.91
|
| Rate for Payer: Multiplan Commercial |
$3,054.34
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,791.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,477.91
|
| Rate for Payer: United Healthcare Commercial |
$3,120.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,477.91
|
| Rate for Payer: United Healthcare VA CCN |
$1,477.91
|
|
|
MRI SPINAL CNL THORACIC W/DYE
|
Facility
|
OP
|
$3,705.86
|
|
|
Service Code
|
CPT 72147
|
| Hospital Charge Code |
6127214701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$854.78 |
| Max. Negotiated Rate |
$3,520.57 |
| Rate for Payer: Aetna of VT Commercial |
$3,520.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$854.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,641.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$854.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,230.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,149.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,001.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,667.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,946.16
|
| Rate for Payer: Cash Price |
$1,852.93
|
| Rate for Payer: Cash Price |
$1,852.93
|
| Rate for Payer: Cigna Commercial |
$2,964.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,964.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,964.69
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,667.64
|
| Rate for Payer: Multiplan Commercial |
$3,446.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,149.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,667.64
|
| Rate for Payer: United Healthcare Commercial |
$3,520.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,667.64
|
| Rate for Payer: United Healthcare VA CCN |
$1,667.64
|
|
|
MRI SPINAL CNL THORACIC W/DYE
|
Facility
|
IP
|
$3,705.86
|
|
|
Service Code
|
CPT 72147
|
| Hospital Charge Code |
6127214701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,742.71 |
| Max. Negotiated Rate |
$3,520.57 |
| Rate for Payer: Aetna of VT Commercial |
$3,520.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,742.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,742.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,149.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,112.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,964.69
|
| Rate for Payer: Cash Price |
$1,852.93
|
| Rate for Payer: Cigna Commercial |
$2,964.69
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,964.69
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,964.69
|
| Rate for Payer: Multiplan Commercial |
$3,446.45
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,149.98
|
| Rate for Payer: United Healthcare Commercial |
$3,520.57
|
|
|
MRI SPINAL CNL THORACIC W/DYE
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
CPT 72147 26
|
| Hospital Charge Code |
9727214701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$113.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$230.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$154.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$208.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$115.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$204.31
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$115.65
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.65
|
| Rate for Payer: United Healthcare VA CCN |
$115.65
|
|
|
MRI SPINAL CNL THORACIC W/DYE
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
CPT 72147 26
|
| Hospital Charge Code |
9727214701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$190.21 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna of VT Commercial |
$244.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$190.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$218.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$215.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$205.60
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$205.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$205.60
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.45
|
| Rate for Payer: United Healthcare Commercial |
$244.15
|
|
|
MRI SPINAL CNL THORACIC W/DYE
|
Professional
|
Both
|
$257.00
|
|
|
Service Code
|
CPT 72147 26
|
| Hospital Charge Code |
9727214701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$854.78 |
| Rate for Payer: Aetna of VT Commercial |
$241.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$854.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$82.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$854.78
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$111.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$138.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$91.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$138.08
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cash Price |
$128.50
|
| Rate for Payer: Cigna Commercial |
$125.22
|
| Rate for Payer: Martins Point Health Care Commercial |
$79.80
|
| Rate for Payer: Multiplan Commercial |
$239.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$122.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$79.80
|
| Rate for Payer: United Healthcare VA CCN |
$79.80
|
|
|
MRI SPINE CERVICAL W/O & W/DYE
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
CPT 72156 26
|
| Hospital Charge Code |
9727215601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$145.71 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Aetna of VT Commercial |
$312.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$294.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$145.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$294.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$198.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$279.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$266.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$148.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$261.56
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$263.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$263.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$263.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$148.05
|
| Rate for Payer: Multiplan Commercial |
$305.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$279.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$148.05
|
| Rate for Payer: United Healthcare Commercial |
$312.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.05
|
| Rate for Payer: United Healthcare VA CCN |
$148.05
|
|
|
MRI SPINE CERVICAL W/O & W/DYE
|
Professional
|
Both
|
$329.00
|
|
|
Service Code
|
CPT 72156 26
|
| Hospital Charge Code |
9727215601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$102.91 |
| Max. Negotiated Rate |
$960.27 |
| Rate for Payer: Aetna of VT Commercial |
$309.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$960.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$106.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$960.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$144.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$185.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$118.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$185.16
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$161.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$102.92
|
| Rate for Payer: Multiplan Commercial |
$305.97
|
| 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 |
$158.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.91
|
| Rate for Payer: United Healthcare VA CCN |
$102.91
|
|
