|
MRI UPPER EXTREMITY W/CONTRAST
|
Facility
|
IP
|
$4,280.77
|
|
|
Service Code
|
CPT 73219 LT
|
| Hospital Charge Code |
61073219LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,168.20 |
| Max. Negotiated Rate |
$4,066.73 |
| Rate for Payer: Aetna of VT Commercial |
$4,066.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,168.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,168.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,638.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,595.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,424.62
|
| Rate for Payer: Cash Price |
$2,140.39
|
| Rate for Payer: Cigna Commercial |
$3,424.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,424.62
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,424.62
|
| Rate for Payer: Multiplan Commercial |
$3,981.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,638.65
|
| Rate for Payer: United Healthcare Commercial |
$4,066.73
|
|
|
MRI UPPER EXTREMITY W/CONTRAST
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 73219 26
|
| Hospital Charge Code |
9727321901
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna of VT Commercial |
$223.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$210.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$104.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$210.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$141.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$199.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$190.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$186.82
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$188.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$188.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$105.75
|
| Rate for Payer: Multiplan Commercial |
$218.55
|
| Rate for Payer: MVP Health Care of NY Commercial |
$199.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$105.75
|
| Rate for Payer: United Healthcare Commercial |
$223.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.75
|
| Rate for Payer: United Healthcare VA CCN |
$105.75
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218
|
| Hospital Charge Code |
6107321801
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,029.62 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,214.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,650.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,221.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,233.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,180.03
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,233.98
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare VA CCN |
$1,233.98
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218 RT
|
| Hospital Charge Code |
61073218RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,029.62 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,214.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,650.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,221.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,233.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,180.03
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,233.98
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare VA CCN |
$1,233.98
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
IP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218 RT
|
| Hospital Charge Code |
61073218RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,029.48 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,303.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,193.74
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218 LT
|
| Hospital Charge Code |
61073218LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,029.62 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,214.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,650.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,221.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,233.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,180.03
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,233.98
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,233.98
|
| Rate for Payer: United Healthcare VA CCN |
$1,233.98
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
IP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218 LT
|
| Hospital Charge Code |
61073218LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,029.48 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,303.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,193.74
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
IP
|
$2,742.17
|
|
|
Service Code
|
CPT 73218
|
| Hospital Charge Code |
6107321801
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,029.48 |
| Max. Negotiated Rate |
$2,605.06 |
| Rate for Payer: Aetna of VT Commercial |
$2,605.06
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,029.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$2,330.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$2,303.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$2,193.74
|
| Rate for Payer: Cash Price |
$1,371.09
|
| Rate for Payer: Cigna Commercial |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$2,193.74
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$2,193.74
|
| Rate for Payer: Multiplan Commercial |
$2,550.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$2,330.84
|
| Rate for Payer: United Healthcare Commercial |
$2,605.06
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
CPT 73218 26
|
| Hospital Charge Code |
9727321801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$60.73 |
| Max. Negotiated Rate |
$1,029.62 |
| Rate for Payer: Aetna of VT Commercial |
$183.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,029.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$85.02
|
| 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 |
$69.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$99.75
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$95.63
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.73
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$600.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.73
|
| Rate for Payer: United Healthcare Commercial |
$93.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.73
|
| Rate for Payer: United Healthcare VA CCN |
$60.73
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 73218 26
|
| Hospital Charge Code |
9727321801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$144.32 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Aetna of VT Commercial |
$185.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$144.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$144.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$163.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$156.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$165.75
|
| Rate for Payer: United Healthcare Commercial |
$185.25
|
|
|
MRI UPPER EXTREMITY W/O CONTR
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 73218 26
|
| Hospital Charge Code |
9727321801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$86.37 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Aetna of VT Commercial |
$185.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$174.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$86.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$174.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$117.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.03
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.75
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$165.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.75
|
| Rate for Payer: United Healthcare Commercial |
$185.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.75
|
| Rate for Payer: United Healthcare VA CCN |
$87.75
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220 LT
|
| Hospital Charge Code |
61073220LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,390.82 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,090.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,841.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,823.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,124.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,124.09
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare VA CCN |
$2,124.09
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220 LT
|
| Hospital Charge Code |
61073220LT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,493.43 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,964.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,776.17
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$309.00
|
|
|
Service Code
|
CPT 73220 26
|
| Hospital Charge Code |
9727322001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$136.86 |
| Max. Negotiated Rate |
$293.55 |
| Rate for Payer: Aetna of VT Commercial |
$293.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$276.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$136.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$276.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$186.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$262.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$250.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$139.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$245.66
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$247.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$139.05
|
| Rate for Payer: Multiplan Commercial |
$287.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$262.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$139.05
|
| Rate for Payer: United Healthcare Commercial |
$293.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$139.05
|
| Rate for Payer: United Healthcare VA CCN |
$139.05
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Professional
|
Both
|
$309.00
|
|
|
Service Code
|
CPT 73220 26
|
| Hospital Charge Code |
9727322001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$96.61 |
| Max. Negotiated Rate |
$1,390.82 |
| Rate for Payer: Aetna of VT Commercial |
$290.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,390.82
|
| 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 |
$1,390.82
|
| 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 |
$159.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$159.49
|
| 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 |
$159.49
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$151.23
|
| Rate for Payer: Martins Point Health Care Commercial |
$96.61
|
| Rate for Payer: Multiplan Commercial |
$287.37
|
| 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 UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220
|
| Hospital Charge Code |
6107322001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,493.43 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,964.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,776.17
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220
|
| Hospital Charge Code |
6107322001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,390.82 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,090.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,841.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,823.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,124.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,124.09
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare VA CCN |
$2,124.09
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220 RT
|
| Hospital Charge Code |
61073220RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,493.43 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,493.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,964.98
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,776.17
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$4,720.21
|
|
|
Service Code
|
CPT 73220 RT
|
| Hospital Charge Code |
61073220RT
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,390.82 |
| Max. Negotiated Rate |
$4,484.20 |
| Rate for Payer: Aetna of VT Commercial |
$4,484.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,090.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,390.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,841.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,012.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,823.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,124.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cash Price |
$2,360.10
|
| Rate for Payer: Cigna Commercial |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,776.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,776.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,124.09
|
| Rate for Payer: Multiplan Commercial |
$4,389.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,012.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare Commercial |
$4,484.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,124.09
|
| Rate for Payer: United Healthcare VA CCN |
$2,124.09
|
|
|
MRI UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$309.00
|
|
|
Service Code
|
CPT 73220 26
|
| Hospital Charge Code |
9727322001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$228.69 |
| Max. Negotiated Rate |
$293.55 |
| Rate for Payer: Aetna of VT Commercial |
$293.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$228.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$228.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$262.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$259.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$247.20
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$247.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$247.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$247.20
|
| Rate for Payer: Multiplan Commercial |
$287.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$262.65
|
| Rate for Payer: United Healthcare Commercial |
$293.55
|
|
|
MR SI JOINT W/O CONTRAST
|
Facility
|
IP
|
$3,083.39
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
6107219502
|
|
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
|
|
|
MR SI JOINT W/O CONTRAST
|
Facility
|
OP
|
$3,083.39
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
6107219502
|
|
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
|
|
|
MR SI JOINT W/O CONTRAST READ
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219502
|
|
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
|
|
|
MR SI JOINT W/O CONTRAST READ
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219502
|
|
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
|
|
|
MR SI JOINT W/O CONTRAST READ
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
CPT 72195 26
|
| Hospital Charge Code |
9727219502
|
|
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
|
|
