|
RPLC GTUBE NO REVJ TRC
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9814376202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$183.36 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$249.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.13
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.30
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare VA CCN |
$186.30
|
|
|
RPLC GTUBE NO REVJ TRC
|
Facility
|
OP
|
$439.45
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
4504376201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$194.63 |
| Max. Negotiated Rate |
$417.48 |
| Rate for Payer: Aetna of VT Commercial |
$417.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$393.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$194.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$393.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$264.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$373.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$355.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$197.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$349.36
|
| Rate for Payer: Cash Price |
$219.72
|
| Rate for Payer: Cigna Commercial |
$351.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$351.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$351.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$197.75
|
| Rate for Payer: Multiplan Commercial |
$408.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$197.75
|
| Rate for Payer: United Healthcare Commercial |
$417.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$197.75
|
| Rate for Payer: United Healthcare VA CCN |
$197.75
|
|
|
RPLC GTUBE NO REVJ TRC
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9814376201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$33.84 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna of VT Commercial |
$389.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$47.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$323.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$323.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$323.58
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$61.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$337.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$337.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$208.90
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.84
|
| Rate for Payer: United Healthcare Commercial |
$52.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.84
|
| Rate for Payer: United Healthcare VA CCN |
$33.84
|
|
|
RPLC GTUBE NO REVJ TRC
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9824376201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$306.40 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.20
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
RPLC GTUBE NO REVJ TRC
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9814376202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$306.40 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.20
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
RPLC GTUBE NO REVJ TRC
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9824376201
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$183.36 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$183.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$249.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$335.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$329.13
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$186.30
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$186.30
|
| Rate for Payer: United Healthcare VA CCN |
$186.30
|
|
|
RPLC GTUBE NO REVJ TRC
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9814376202
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$33.84 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna of VT Commercial |
$389.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$370.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$47.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$323.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$323.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$38.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$323.58
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$61.99
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$337.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$337.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$208.90
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$48.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.84
|
| Rate for Payer: United Healthcare Commercial |
$52.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.84
|
| Rate for Payer: United Healthcare VA CCN |
$33.84
|
|
|
RPLC GTUBE NO REVJ TRC
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 43762
|
| Hospital Charge Code |
9814376201
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$306.40 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of VT Commercial |
$393.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$306.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$347.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$331.20
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$331.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$385.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$351.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
RP LOCLZJ TUM 1 AREA 1 D IMG
|
Professional
|
Both
|
$93.00
|
|
|
Service Code
|
CPT 78800
|
| Hospital Charge Code |
9727880001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$86.49 |
| Max. Negotiated Rate |
$874.84 |
| Rate for Payer: Aetna of VT Commercial |
$87.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$874.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$225.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$874.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$305.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$334.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$334.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$251.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$334.34
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$337.94
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$351.79
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$351.79
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.46
|
| Rate for Payer: Multiplan Commercial |
$86.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$218.46
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$218.46
|
| Rate for Payer: United Healthcare Commercial |
$336.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$218.46
|
| Rate for Payer: United Healthcare VA CCN |
$218.46
|
|
|
RP LOCLZJ TUM 1 AREA 1 D IMG
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
CPT 78800
|
| Hospital Charge Code |
9727880001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$68.83 |
| Max. Negotiated Rate |
$88.35 |
| Rate for Payer: Aetna of VT Commercial |
$88.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$68.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$68.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$79.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$78.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$74.40
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$74.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$74.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$74.40
|
| Rate for Payer: Multiplan Commercial |
$86.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$79.05
|
| Rate for Payer: United Healthcare Commercial |
$88.35
|
|
|
RP LOCLZJ TUM 1 AREA 1 D IMG
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
CPT 78800
|
| Hospital Charge Code |
9727880001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$41.19 |
| Max. Negotiated Rate |
$88.35 |
| Rate for Payer: Aetna of VT Commercial |
$88.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$83.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$41.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$83.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$55.99
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$79.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$75.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$41.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$73.94
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$74.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$74.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$74.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$41.85
|
| Rate for Payer: Multiplan Commercial |
$86.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$79.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$41.85
|
| Rate for Payer: United Healthcare Commercial |
$88.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.85
|
| Rate for Payer: United Healthcare VA CCN |
$41.85
|
|
|
RP LOCLZJ TUM 1 AREA 1 D IMG
|
Facility
|
OP
|
$2,075.24
|
|
|
Service Code
|
CPT 78800
|
| Hospital Charge Code |
3417880001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$874.84 |
| Max. Negotiated Rate |
$1,971.48 |
| Rate for Payer: Aetna of VT Commercial |
$1,971.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$874.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$919.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$874.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$1,249.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,763.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,680.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$933.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,649.82
|
| Rate for Payer: Cash Price |
$1,037.62
|
| Rate for Payer: Cash Price |
$1,037.62
|
| Rate for Payer: Cigna Commercial |
$1,660.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,660.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,660.19
|
| Rate for Payer: Martins Point Health Care Commercial |
$933.86
|
| Rate for Payer: Multiplan Commercial |
$1,929.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,763.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$933.86
|
| Rate for Payer: United Healthcare Commercial |
$1,971.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$933.86
|
| Rate for Payer: United Healthcare VA CCN |
$933.86
|
|
|
RP LOCLZJ TUM 1 AREA 1 D IMG
|
Facility
|
IP
|
$2,075.24
|
|
|
Service Code
|
CPT 78800
|
| Hospital Charge Code |
3417880001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,535.89 |
| Max. Negotiated Rate |
$1,971.48 |
| Rate for Payer: Aetna of VT Commercial |
$1,971.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,535.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,535.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,763.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,743.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,660.19
|
| Rate for Payer: Cash Price |
$1,037.62
|
| Rate for Payer: Cigna Commercial |
$1,660.19
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,660.19
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,660.19
|
| Rate for Payer: Multiplan Commercial |
$1,929.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,763.95
|
| Rate for Payer: United Healthcare Commercial |
$1,971.48
|
|
|
RP LOCLZJ TUM WHBDY 1 D IMG
|
Professional
|
Both
|
$114.00
|
|
|
Service Code
|
CPT 78802
|
| Hospital Charge Code |
9727880201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$106.02 |
| Max. Negotiated Rate |
$1,061.20 |
| Rate for Payer: Aetna of VT Commercial |
$107.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,061.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$271.86
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,061.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$369.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$443.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$443.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$303.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$443.75
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$410.18
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$424.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$424.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$263.94
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$263.94
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$263.94
|
| Rate for Payer: United Healthcare Commercial |
$406.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$263.94
|
| Rate for Payer: United Healthcare VA CCN |
$263.94
|
|
|
RP LOCLZJ TUM WHBDY 1 D IMG
|
Facility
|
IP
|
$4,020.19
|
|
|
Service Code
|
CPT 78802
|
| Hospital Charge Code |
3417880201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$2,975.34 |
| Max. Negotiated Rate |
$3,819.18 |
| Rate for Payer: Aetna of VT Commercial |
$3,819.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,975.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,975.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,417.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,376.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,216.15
|
| Rate for Payer: Cash Price |
$2,010.10
|
| Rate for Payer: Cigna Commercial |
$3,216.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,216.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,216.15
|
| Rate for Payer: Multiplan Commercial |
$3,738.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,417.16
|
| Rate for Payer: United Healthcare Commercial |
$3,819.18
|
|
|
RP LOCLZJ TUM WHBDY 1 D IMG
|
Facility
|
OP
|
$4,020.19
|
|
|
Service Code
|
CPT 78802
|
| Hospital Charge Code |
3417880201
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,061.20 |
| Max. Negotiated Rate |
$3,819.18 |
| Rate for Payer: Aetna of VT Commercial |
$3,819.18
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,061.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$1,780.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,061.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,420.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$3,417.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,256.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$1,809.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,196.05
|
| Rate for Payer: Cash Price |
$2,010.10
|
| Rate for Payer: Cash Price |
$2,010.10
|
| Rate for Payer: Cigna Commercial |
$3,216.15
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,216.15
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,216.15
|
| Rate for Payer: Martins Point Health Care Commercial |
$1,809.09
|
| Rate for Payer: Multiplan Commercial |
$3,738.78
|
| Rate for Payer: MVP Health Care of NY Commercial |
$3,417.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$1,809.09
|
| Rate for Payer: United Healthcare Commercial |
$3,819.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.09
|
| Rate for Payer: United Healthcare VA CCN |
$1,809.09
|
|
|
RP LOCLZJ TUM WHBDY 1 D IMG
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 78802
|
| Hospital Charge Code |
9727880201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$84.37 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna of VT Commercial |
$108.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$84.37
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$95.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$91.20
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$91.20
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.90
|
| Rate for Payer: United Healthcare Commercial |
$108.30
|
|
|
RP LOCLZJ TUM WHBDY 1 D IMG
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 78802
|
| Hospital Charge Code |
9727880201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.49 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna of VT Commercial |
$108.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$50.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$102.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$68.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$96.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$92.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$51.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$90.63
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$91.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$91.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$51.30
|
| Rate for Payer: Multiplan Commercial |
$106.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$96.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$51.30
|
| Rate for Payer: United Healthcare Commercial |
$108.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.30
|
| Rate for Payer: United Healthcare VA CCN |
$51.30
|
|
|
RP LOCLZJ TUM WHBDY 2+D IMG
|
Professional
|
Both
|
$142.00
|
|
|
Service Code
|
CPT 78804
|
| Hospital Charge Code |
9727880401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$132.06 |
| Max. Negotiated Rate |
$2,338.97 |
| Rate for Payer: Aetna of VT Commercial |
$133.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,338.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$563.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,338.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$766.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$854.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$854.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$629.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$854.28
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$854.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$878.94
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$878.94
|
| Rate for Payer: Martins Point Health Care Commercial |
$547.32
|
| Rate for Payer: Multiplan Commercial |
$132.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$547.32
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$547.32
|
| Rate for Payer: United Healthcare Commercial |
$841.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$547.32
|
| Rate for Payer: United Healthcare VA CCN |
$547.32
|
|
|
RP LOCLZJ TUM WHBDY 2+D IMG
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT 78804
|
| Hospital Charge Code |
9727880401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$62.89 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Aetna of VT Commercial |
$134.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$127.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$62.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$127.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$85.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$120.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$115.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$63.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$112.89
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$113.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$113.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$113.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$63.90
|
| Rate for Payer: Multiplan Commercial |
$132.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$120.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$63.90
|
| Rate for Payer: United Healthcare Commercial |
$134.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.90
|
| Rate for Payer: United Healthcare VA CCN |
$63.90
|
|
|
RP LOCLZJ TUM WHBDY 2+D IMG
|
Facility
|
IP
|
$4,870.14
|
|
|
Service Code
|
CPT 78804
|
| Hospital Charge Code |
3417880401
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$3,604.39 |
| Max. Negotiated Rate |
$4,626.63 |
| Rate for Payer: Aetna of VT Commercial |
$4,626.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$3,604.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$3,604.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,139.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$4,090.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,896.11
|
| Rate for Payer: Cash Price |
$2,435.07
|
| Rate for Payer: Cigna Commercial |
$3,896.11
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,896.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,896.11
|
| Rate for Payer: Multiplan Commercial |
$4,529.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,139.62
|
| Rate for Payer: United Healthcare Commercial |
$4,626.63
|
|
|
RP LOCLZJ TUM WHBDY 2+D IMG
|
Facility
|
OP
|
$4,870.14
|
|
|
Service Code
|
CPT 78804
|
| Hospital Charge Code |
3417880401
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$2,156.99 |
| Max. Negotiated Rate |
$4,626.63 |
| Rate for Payer: Aetna of VT Commercial |
$4,626.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$2,338.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$2,156.99
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$2,338.97
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$2,931.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$4,139.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$3,944.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$2,191.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$3,871.76
|
| Rate for Payer: Cash Price |
$2,435.07
|
| Rate for Payer: Cash Price |
$2,435.07
|
| Rate for Payer: Cigna Commercial |
$3,896.11
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$3,896.11
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$3,896.11
|
| Rate for Payer: Martins Point Health Care Commercial |
$2,191.56
|
| Rate for Payer: Multiplan Commercial |
$4,529.23
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,139.62
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$2,191.56
|
| Rate for Payer: United Healthcare Commercial |
$4,626.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,191.56
|
| Rate for Payer: United Healthcare VA CCN |
$2,191.56
|
|
|
RP LOCLZJ TUM WHBDY 2+D IMG
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT 78804
|
| Hospital Charge Code |
9727880401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$105.09 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Aetna of VT Commercial |
$134.90
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$105.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$105.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$120.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$119.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$113.60
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cigna Commercial |
$113.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$113.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$113.60
|
| Rate for Payer: Multiplan Commercial |
$132.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$120.70
|
| Rate for Payer: United Healthcare Commercial |
$134.90
|
|
|
RPR AA HRN 1ST 3-10 NCR/STRN
|
Facility
|
OP
|
$1,607.00
|
|
|
Service Code
|
CPT 49594
|
| Hospital Charge Code |
9824959401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$711.74 |
| Max. Negotiated Rate |
$1,526.65 |
| Rate for Payer: Aetna of VT Commercial |
$1,526.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,439.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$711.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,439.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$967.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,365.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,301.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$723.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,277.57
|
| Rate for Payer: Cash Price |
$803.50
|
| Rate for Payer: Cigna Commercial |
$1,285.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,285.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,285.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$723.15
|
| Rate for Payer: Multiplan Commercial |
$1,494.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,365.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$723.15
|
| Rate for Payer: United Healthcare Commercial |
$1,526.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$723.15
|
| Rate for Payer: United Healthcare VA CCN |
$723.15
|
|
|
RPR AA HRN 1ST 3-10 NCR/STRN
|
Facility
|
IP
|
$1,607.00
|
|
|
Service Code
|
CPT 49594
|
| Hospital Charge Code |
9824959401
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,189.34 |
| Max. Negotiated Rate |
$1,526.65 |
| Rate for Payer: Aetna of VT Commercial |
$1,526.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,189.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,189.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,365.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,349.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,285.60
|
| Rate for Payer: Cash Price |
$803.50
|
| Rate for Payer: Cigna Commercial |
$1,285.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,285.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,285.60
|
| Rate for Payer: Multiplan Commercial |
$1,494.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,365.95
|
| Rate for Payer: United Healthcare Commercial |
$1,526.65
|
|
