|
NM HEPATOBIL SYST IMAGE W/DRUG
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 78227 26
|
| Hospital Charge Code |
9727822701
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$96.21 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Aetna of VT Commercial |
$123.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$96.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$96.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$110.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$109.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$104.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$104.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$104.00
|
| Rate for Payer: Multiplan Commercial |
$120.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$110.50
|
| Rate for Payer: United Healthcare Commercial |
$123.50
|
|
|
NM HEPATOBIL SYST IMAGE W/DRUG
|
Facility
|
OP
|
$1,873.61
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
3417822701
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$829.82 |
| Max. Negotiated Rate |
$1,779.93 |
| Rate for Payer: Aetna of VT Commercial |
$1,779.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,544.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$829.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,544.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,127.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,592.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,517.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$843.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,489.52
|
| Rate for Payer: Cash Price |
$936.80
|
| Rate for Payer: Cash Price |
$936.80
|
| Rate for Payer: Cigna Commercial |
$1,498.89
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,498.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,498.89
|
| Rate for Payer: Martins Point Health Care Commercial |
$843.12
|
| Rate for Payer: Multiplan Commercial |
$1,742.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,592.57
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$843.12
|
| Rate for Payer: United Healthcare Commercial |
$1,779.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$843.12
|
| Rate for Payer: United Healthcare VA CCN |
$843.12
|
|
|
NM HEPATOBIL SYST IMAGE W/DRUG
|
Facility
|
IP
|
$1,873.61
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
3417822701
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,386.66 |
| Max. Negotiated Rate |
$1,779.93 |
| Rate for Payer: Aetna of VT Commercial |
$1,779.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,386.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,386.66
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,592.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,573.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,498.89
|
| Rate for Payer: Cash Price |
$936.80
|
| Rate for Payer: Cigna Commercial |
$1,498.89
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,498.89
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,498.89
|
| Rate for Payer: Multiplan Commercial |
$1,742.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,592.57
|
| Rate for Payer: United Healthcare Commercial |
$1,779.93
|
|
|
NM MYCARD SPECT MULTIPL STUDY
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
CPT 78452 26
|
| Hospital Charge Code |
9727845201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$71.22 |
| Max. Negotiated Rate |
$1,553.16 |
| Rate for Payer: Aetna of VT Commercial |
$214.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,553.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$73.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,553.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$99.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$120.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$120.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$81.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.91
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$107.96
|
| Rate for Payer: Martins Point Health Care Commercial |
$71.22
|
| Rate for Payer: Multiplan Commercial |
$212.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$71.23
|
| Rate for Payer: United Healthcare Commercial |
$109.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.23
|
| Rate for Payer: United Healthcare VA CCN |
$71.23
|
|
|
NM MYCARD SPECT MULTIPL STUDY
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 78452 26
|
| Hospital Charge Code |
9727845201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$168.74 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Aetna of VT Commercial |
$216.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$168.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$168.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$191.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.40
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$182.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$182.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$182.40
|
| Rate for Payer: Multiplan Commercial |
$212.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$193.80
|
| Rate for Payer: United Healthcare Commercial |
$216.60
|
|
|
NM MYCARD SPECT MULTIPL STUDY
|
Facility
|
IP
|
$4,076.03
|
|
|
Service Code
|
CPT 78452
|
| Hospital Charge Code |
3417845201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$3,016.67 |
| Max. Negotiated Rate |
$3,872.23 |
| Rate for Payer: Aetna of VT Commercial |
$3,872.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,016.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,016.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,464.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,423.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,260.82
|
| Rate for Payer: Cash Price |
$2,038.02
|
| Rate for Payer: Cigna Commercial |
$3,260.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,260.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,260.82
|
| Rate for Payer: Multiplan Commercial |
$3,790.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,464.63
|
| Rate for Payer: United Healthcare Commercial |
$3,872.23
|
|
|
NM MYCARD SPECT MULTIPL STUDY
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 78452 26
|
| Hospital Charge Code |
9727845201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$100.98 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Aetna of VT Commercial |
$216.60
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$204.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$100.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$204.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$137.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$184.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$102.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$181.26
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$182.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$182.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$182.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$102.60
|
| Rate for Payer: Multiplan Commercial |
$212.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$193.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$102.60
|
| Rate for Payer: United Healthcare Commercial |
$216.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.60
|
| Rate for Payer: United Healthcare VA CCN |
$102.60
|
|
|
NM MYCARD SPECT MULTIPL STUDY
|
Facility
|
OP
|
$4,076.03
|
|
|
Service Code
|
CPT 78452
|
| Hospital Charge Code |
3417845201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,553.16 |
| Max. Negotiated Rate |
$3,872.23 |
| Rate for Payer: Aetna of VT Commercial |
$3,872.23
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,553.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,805.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,553.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,453.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,464.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,301.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,834.21
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,240.44
|
| Rate for Payer: Cash Price |
$2,038.02
|
| Rate for Payer: Cash Price |
$2,038.02
|
| Rate for Payer: Cigna Commercial |
$3,260.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,260.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,260.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,834.21
|
| Rate for Payer: Multiplan Commercial |
$3,790.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,464.63
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,834.21
|
| Rate for Payer: United Healthcare Commercial |
$3,872.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,834.21
|
| Rate for Payer: United Healthcare VA CCN |
$1,834.21
|
|
|
NM MYCARD SPECT REST OR STRESS
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 78451 26
|
| Hospital Charge Code |
9727845101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$85.48 |
| Max. Negotiated Rate |
$183.35 |
| Rate for Payer: Aetna of VT Commercial |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$85.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$172.91
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$116.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$156.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$86.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$153.44
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$154.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$154.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$154.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$86.85
|
| Rate for Payer: Multiplan Commercial |
$179.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$86.85
|
| Rate for Payer: United Healthcare Commercial |
$183.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.85
|
| Rate for Payer: United Healthcare VA CCN |
$86.85
|
|
|
NM MYCARD SPECT REST OR STRESS
|
Facility
|
OP
|
$2,092.05
|
|
|
Service Code
|
CPT 78451
|
| Hospital Charge Code |
3417845101
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$926.57 |
| Max. Negotiated Rate |
$1,987.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,987.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,082.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$926.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,082.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,259.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,778.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,694.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$941.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,663.18
|
| Rate for Payer: Cash Price |
$1,046.03
|
| Rate for Payer: Cash Price |
$1,046.03
|
| Rate for Payer: Cigna Commercial |
$1,673.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,673.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,673.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$941.42
|
| Rate for Payer: Multiplan Commercial |
$1,945.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,778.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$941.42
|
| Rate for Payer: United Healthcare Commercial |
$1,987.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$941.42
|
| Rate for Payer: United Healthcare VA CCN |
$941.42
|
|
|
NM MYCARD SPECT REST OR STRESS
|
Facility
|
IP
|
$2,092.05
|
|
|
Service Code
|
CPT 78451
|
| Hospital Charge Code |
3417845101
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,548.33 |
| Max. Negotiated Rate |
$1,987.45 |
| Rate for Payer: Aetna of VT Commercial |
$1,987.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,548.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,548.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,778.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,757.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,673.64
|
| Rate for Payer: Cash Price |
$1,046.03
|
| Rate for Payer: Cigna Commercial |
$1,673.64
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,673.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,673.64
|
| Rate for Payer: Multiplan Commercial |
$1,945.61
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,778.24
|
| Rate for Payer: United Healthcare Commercial |
$1,987.45
|
|
|
NM MYCARD SPECT REST OR STRESS
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 78451 26
|
| Hospital Charge Code |
9727845101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$1,082.71 |
| Rate for Payer: Aetna of VT Commercial |
$181.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,082.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,082.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$84.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$103.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$103.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$69.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$103.02
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$91.52
|
| Rate for Payer: Martins Point Health Care Commercial |
$60.40
|
| Rate for Payer: Multiplan Commercial |
$179.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$60.40
|
| Rate for Payer: United Healthcare Commercial |
$92.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.40
|
| Rate for Payer: United Healthcare VA CCN |
$60.40
|
|
|
NM MYCARD SPECT REST OR STRESS
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 78451 26
|
| Hospital Charge Code |
9727845101
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$142.84 |
| Max. Negotiated Rate |
$183.35 |
| Rate for Payer: Aetna of VT Commercial |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$142.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$142.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$162.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$154.40
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$154.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$154.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$154.40
|
| Rate for Payer: Multiplan Commercial |
$179.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$164.05
|
| Rate for Payer: United Healthcare Commercial |
$183.35
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 78803 26
|
| Hospital Charge Code |
9727880301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$111.76 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna of VT Commercial |
$143.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$111.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$111.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.80
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.80
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.35
|
| Rate for Payer: United Healthcare Commercial |
$143.45
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 78803 26
|
| Hospital Charge Code |
9727880301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$47.17 |
| Max. Negotiated Rate |
$1,290.75 |
| Rate for Payer: Aetna of VT Commercial |
$141.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$48.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$66.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$80.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$80.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$54.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$80.20
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$71.41
|
| Rate for Payer: Martins Point Health Care Commercial |
$47.17
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$47.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$47.17
|
| Rate for Payer: United Healthcare Commercial |
$72.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.17
|
| Rate for Payer: United Healthcare VA CCN |
$47.17
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Professional
|
Both
|
$1,657.50
|
|
|
Service Code
|
CPT 78803
|
| Hospital Charge Code |
3417880301
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$324.71 |
| Max. Negotiated Rate |
$1,558.05 |
| Rate for Payer: Aetna of VT Commercial |
$1,558.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$334.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$454.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$526.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$526.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$373.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$526.18
|
| Rate for Payer: Cash Price |
$828.75
|
| Rate for Payer: Cash Price |
$828.75
|
| Rate for Payer: Cigna Commercial |
$506.42
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$521.50
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$521.50
|
| Rate for Payer: Martins Point Health Care Commercial |
$324.71
|
| Rate for Payer: Multiplan Commercial |
$1,541.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$324.72
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$324.72
|
| Rate for Payer: United Healthcare Commercial |
$499.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.72
|
| Rate for Payer: United Healthcare VA CCN |
$324.72
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Facility
|
IP
|
$1,657.50
|
|
|
Service Code
|
CPT 78803
|
| Hospital Charge Code |
3417880301
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,226.72 |
| Max. Negotiated Rate |
$1,574.62 |
| Rate for Payer: Aetna of VT Commercial |
$1,574.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,226.72
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,226.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,408.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,392.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,326.00
|
| Rate for Payer: Cash Price |
$828.75
|
| Rate for Payer: Cigna Commercial |
$1,326.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,326.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,326.00
|
| Rate for Payer: Multiplan Commercial |
$1,541.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,408.88
|
| Rate for Payer: United Healthcare Commercial |
$1,574.62
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 78803 26
|
| Hospital Charge Code |
9727880301
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$66.88 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna of VT Commercial |
$143.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$135.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$66.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$135.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$90.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$128.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$122.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$67.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$120.05
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$120.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$120.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$67.95
|
| Rate for Payer: Multiplan Commercial |
$140.43
|
| Rate for Payer: MVP Health Care of NY Commercial |
$128.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$67.95
|
| Rate for Payer: United Healthcare Commercial |
$143.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.95
|
| Rate for Payer: United Healthcare VA CCN |
$67.95
|
|
|
NM RP LOCLZJ TUM SPECT 1 AREA
|
Facility
|
OP
|
$1,657.50
|
|
|
Service Code
|
CPT 78803
|
| Hospital Charge Code |
3417880301
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$734.11 |
| Max. Negotiated Rate |
$1,574.62 |
| Rate for Payer: Aetna of VT Commercial |
$1,574.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$734.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,290.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$997.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,408.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,342.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$745.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,317.71
|
| Rate for Payer: Cash Price |
$828.75
|
| Rate for Payer: Cash Price |
$828.75
|
| Rate for Payer: Cigna Commercial |
$1,326.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,326.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,326.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$745.88
|
| Rate for Payer: Multiplan Commercial |
$1,541.47
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,408.88
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$745.88
|
| Rate for Payer: United Healthcare Commercial |
$1,574.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$745.88
|
| Rate for Payer: United Healthcare VA CCN |
$745.88
|
|
|
NONINVASIV PULSE OX MULT DETER
|
Facility
|
IP
|
$132.35
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
4609476101
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$97.95 |
| Max. Negotiated Rate |
$125.73 |
| Rate for Payer: Aetna of VT Commercial |
$125.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$97.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$97.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$111.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.88
|
| Rate for Payer: Cash Price |
$66.17
|
| Rate for Payer: Cigna Commercial |
$105.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$105.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$105.88
|
| Rate for Payer: Multiplan Commercial |
$123.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$125.73
|
|
|
NONINVASIV PULSE OX MULT DETER
|
Facility
|
OP
|
$132.35
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
4609476101
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$58.62 |
| Max. Negotiated Rate |
$125.73 |
| Rate for Payer: Aetna of VT Commercial |
$125.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$58.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$79.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$107.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$59.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$105.22
|
| Rate for Payer: Cash Price |
$66.17
|
| Rate for Payer: Cigna Commercial |
$105.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$105.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$105.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$59.56
|
| Rate for Payer: Multiplan Commercial |
$123.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$112.50
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$59.56
|
| Rate for Payer: United Healthcare Commercial |
$125.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59.56
|
| Rate for Payer: United Healthcare VA CCN |
$59.56
|
|
|
NONINVASIV PULSE OX MULT DETER
|
Professional
|
Both
|
$132.35
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
4609476101
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$124.41 |
| Rate for Payer: Aetna of VT Commercial |
$124.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$118.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$118.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$11.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$11.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$4.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$11.02
|
| Rate for Payer: Cash Price |
$66.17
|
| Rate for Payer: Cash Price |
$66.17
|
| Rate for Payer: Cigna Commercial |
$5.55
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$6.17
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$6.17
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$123.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.70
|
| Rate for Payer: United Healthcare Commercial |
$5.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.70
|
| Rate for Payer: United Healthcare VA CCN |
$3.70
|
|
|
NONINVASIV PULSE OX SNGL DETER
|
Facility
|
IP
|
$41.62
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
4609476001
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$39.54 |
| Rate for Payer: Aetna of VT Commercial |
$39.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$30.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$30.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$35.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$34.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.30
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cigna Commercial |
$33.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$33.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$33.30
|
| Rate for Payer: Multiplan Commercial |
$38.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.38
|
| Rate for Payer: United Healthcare Commercial |
$39.54
|
|
|
NONINVASIV PULSE OX SNGL DETER
|
Professional
|
Both
|
$41.62
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
4609476001
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$39.12 |
| Rate for Payer: Aetna of VT Commercial |
$39.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$37.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$3.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$37.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$4.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$7.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$7.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$7.13
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cigna Commercial |
$3.62
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$5.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$5.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$38.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.80
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$3.38
|
| Rate for Payer: United Healthcare Commercial |
$5.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.38
|
| Rate for Payer: United Healthcare VA CCN |
$3.38
|
|
|
NONINVASIV PULSE OX SNGL DETER
|
Facility
|
OP
|
$41.62
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
4609476001
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$39.54 |
| Rate for Payer: Aetna of VT Commercial |
$39.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$37.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$18.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$37.29
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$25.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$35.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$33.71
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$18.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$33.09
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cigna Commercial |
$33.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$33.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$33.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$18.73
|
| Rate for Payer: Multiplan Commercial |
$38.71
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.38
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$18.73
|
| Rate for Payer: United Healthcare Commercial |
$39.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.73
|
| Rate for Payer: United Healthcare VA CCN |
$18.73
|
|
