|
XR ANKLE 2 VIEWS
|
Facility
|
IP
|
$449.79
|
|
|
Service Code
|
CPT 73600
|
| Hospital Charge Code |
3207360001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$332.89 |
| Max. Negotiated Rate |
$427.30 |
| Rate for Payer: Aetna of VT Commercial |
$427.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$332.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$332.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$382.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$377.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$359.83
|
| Rate for Payer: Cash Price |
$224.90
|
| Rate for Payer: Cigna Commercial |
$359.83
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$359.83
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$359.83
|
| Rate for Payer: Multiplan Commercial |
$418.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$382.32
|
| Rate for Payer: United Healthcare Commercial |
$427.30
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$473.57
|
|
|
Service Code
|
CPT 73610 RT
|
| Hospital Charge Code |
32073610RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$350.49 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.86
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$473.57
|
|
|
Service Code
|
CPT 73610 RT
|
| Hospital Charge Code |
32073610RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.61 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$285.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$383.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$213.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.49
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$213.11
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare VA CCN |
$213.11
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
CPT 73610 26
|
| Hospital Charge Code |
9727361001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$122.61 |
| Rate for Payer: Aetna of VT Commercial |
$68.62
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$8.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$11.07
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$12.39
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$12.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$67.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7.91
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$7.91
|
| Rate for Payer: United Healthcare Commercial |
$12.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.91
|
| Rate for Payer: United Healthcare VA CCN |
$7.91
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$555.26
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
3207361001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.61 |
| Max. Negotiated Rate |
$527.50 |
| Rate for Payer: Aetna of VT Commercial |
$527.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$245.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$334.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$471.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$449.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$249.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$441.43
|
| Rate for Payer: Cash Price |
$277.63
|
| Rate for Payer: Cash Price |
$277.63
|
| Rate for Payer: Cigna Commercial |
$444.21
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$444.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$444.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$249.87
|
| Rate for Payer: Multiplan Commercial |
$516.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$471.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$249.87
|
| Rate for Payer: United Healthcare Commercial |
$527.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$249.87
|
| Rate for Payer: United Healthcare VA CCN |
$249.87
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Professional
|
Both
|
$473.57
|
|
|
Service Code
|
CPT 73610 LT
|
| Hospital Charge Code |
32073610LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$445.16 |
| Rate for Payer: Aetna of VT Commercial |
$445.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$47.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$47.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.08
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$53.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.74
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: United Healthcare Commercial |
$402.53
|
| Rate for Payer: United Healthcare VA CCN |
$189.43
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 73610 26
|
| Hospital Charge Code |
9727361001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$54.03 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Aetna of VT Commercial |
$69.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$54.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$54.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$61.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.40
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$58.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.40
|
| Rate for Payer: Multiplan Commercial |
$67.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.05
|
| Rate for Payer: United Healthcare Commercial |
$69.35
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT 73610 26
|
| Hospital Charge Code |
9727361001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Aetna of VT Commercial |
$69.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$32.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$43.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$59.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$32.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$58.03
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$58.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$58.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$58.40
|
| Rate for Payer: Martins Point Health Care Commercial |
$32.85
|
| Rate for Payer: Multiplan Commercial |
$67.89
|
| Rate for Payer: MVP Health Care of NY Commercial |
$62.05
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$32.85
|
| Rate for Payer: United Healthcare Commercial |
$69.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.85
|
| Rate for Payer: United Healthcare VA CCN |
$32.85
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$555.26
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
3207361001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$410.95 |
| Max. Negotiated Rate |
$527.50 |
| Rate for Payer: Aetna of VT Commercial |
$527.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$410.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$410.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$471.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$466.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$444.21
|
| Rate for Payer: Cash Price |
$277.63
|
| Rate for Payer: Cigna Commercial |
$444.21
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$444.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$444.21
|
| Rate for Payer: Multiplan Commercial |
$516.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$471.97
|
| Rate for Payer: United Healthcare Commercial |
$527.50
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$473.57
|
|
|
Service Code
|
CPT 73610 LT
|
| Hospital Charge Code |
32073610LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$350.49 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.86
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Professional
|
Both
|
$473.57
|
|
|
Service Code
|
CPT 73610 RT
|
| Hospital Charge Code |
32073610RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$445.16 |
| Rate for Payer: Aetna of VT Commercial |
$445.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$47.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$47.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.08
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$53.26
|
| Rate for Payer: Martins Point Health Care Commercial |
$34.74
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: United Healthcare Commercial |
$402.53
|
| Rate for Payer: United Healthcare VA CCN |
$189.43
|
|
|
XR ANKLE COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$473.57
|
|
|
Service Code
|
CPT 73610 LT
|
| Hospital Charge Code |
32073610LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.61 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$285.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$383.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$213.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.49
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$213.11
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare VA CCN |
$213.11
|
|
|
XR ANTEGRADE UROGRAPHY S&R
|
Facility
|
OP
|
$1,597.19
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
3207442501
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$486.75 |
| Max. Negotiated Rate |
$1,517.33 |
| Rate for Payer: Aetna of VT Commercial |
$1,517.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$707.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$961.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,357.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,293.72
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$718.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,269.77
|
| Rate for Payer: Cash Price |
$798.60
|
| Rate for Payer: Cash Price |
$798.60
|
| Rate for Payer: Cigna Commercial |
$1,277.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,277.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,277.75
|
| Rate for Payer: Martins Point Health Care Commercial |
$718.74
|
| Rate for Payer: Multiplan Commercial |
$1,485.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,357.61
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$718.74
|
| Rate for Payer: United Healthcare Commercial |
$1,517.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$718.74
|
| Rate for Payer: United Healthcare VA CCN |
$718.74
|
|
|
XR ANTEGRADE UROGRAPHY S&R
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 74425 26
|
| Hospital Charge Code |
9727442501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$72.64 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Aetna of VT Commercial |
$155.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$146.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$72.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$146.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$98.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$132.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$130.38
|
| Rate for Payer: Cash Price |
$82.00
|
| Rate for Payer: Cigna Commercial |
$131.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$73.80
|
| Rate for Payer: Multiplan Commercial |
$152.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$139.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$73.80
|
| Rate for Payer: United Healthcare Commercial |
$155.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.80
|
| Rate for Payer: United Healthcare VA CCN |
$73.80
|
|
|
XR ANTEGRADE UROGRAPHY S&R
|
Facility
|
IP
|
$1,597.19
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
3207442501
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,182.08 |
| Max. Negotiated Rate |
$1,517.33 |
| Rate for Payer: Aetna of VT Commercial |
$1,517.33
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,182.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,182.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,357.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,341.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,277.75
|
| Rate for Payer: Cash Price |
$798.60
|
| Rate for Payer: Cigna Commercial |
$1,277.75
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,277.75
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,277.75
|
| Rate for Payer: Multiplan Commercial |
$1,485.39
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,357.61
|
| Rate for Payer: United Healthcare Commercial |
$1,517.33
|
|
|
XR ANTEGRADE UROGRAPHY S&R
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 74425 26
|
| Hospital Charge Code |
9727442501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$121.38 |
| Max. Negotiated Rate |
$155.80 |
| Rate for Payer: Aetna of VT Commercial |
$155.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$121.38
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$121.38
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$139.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$137.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$131.20
|
| Rate for Payer: Cash Price |
$82.00
|
| Rate for Payer: Cigna Commercial |
$131.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$131.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$131.20
|
| Rate for Payer: Multiplan Commercial |
$152.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$139.40
|
| Rate for Payer: United Healthcare Commercial |
$155.80
|
|
|
XR ANTEGRADE UROGRAPHY S&R
|
Professional
|
Both
|
$164.00
|
|
|
Service Code
|
CPT 74425 26
|
| Hospital Charge Code |
9727442501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$22.78 |
| Max. Negotiated Rate |
$486.75 |
| Rate for Payer: Aetna of VT Commercial |
$154.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$486.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$31.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$30.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$30.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$26.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$30.56
|
| Rate for Payer: Cash Price |
$82.00
|
| Rate for Payer: Cash Price |
$82.00
|
| Rate for Payer: Cigna Commercial |
$33.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$22.78
|
| Rate for Payer: Multiplan Commercial |
$152.52
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.78
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$22.78
|
| Rate for Payer: United Healthcare Commercial |
$35.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.78
|
| Rate for Payer: United Healthcare VA CCN |
$22.78
|
|
|
X-RAY EXAM NECK SPINE 6/>VWS
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
9727205201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$115.46 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna of VT Commercial |
$148.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$115.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$115.46
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$131.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$124.80
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$124.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.80
|
| Rate for Payer: Multiplan Commercial |
$145.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$132.60
|
| Rate for Payer: United Healthcare Commercial |
$148.20
|
|
|
X-RAY EXAM NECK SPINE 6/>VWS
|
Facility
|
IP
|
$894.41
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
3207205201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$661.95 |
| Max. Negotiated Rate |
$849.69 |
| Rate for Payer: Aetna of VT Commercial |
$849.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$661.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$661.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$760.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$751.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$715.53
|
| Rate for Payer: Cash Price |
$447.20
|
| Rate for Payer: Cigna Commercial |
$715.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$715.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$715.53
|
| Rate for Payer: Multiplan Commercial |
$831.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$760.25
|
| Rate for Payer: United Healthcare Commercial |
$849.69
|
|
|
X-RAY EXAM NECK SPINE 6/>VWS
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9727205201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$145.08 |
| Max. Negotiated Rate |
$677.47 |
| Rate for Payer: Aetna of VT Commercial |
$146.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$256.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$677.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$348.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$339.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$286.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.13
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$370.87
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$400.64
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$400.64
|
| Rate for Payer: Martins Point Health Care Commercial |
$248.98
|
| Rate for Payer: Multiplan Commercial |
$145.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$248.98
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare Commercial |
$383.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$248.98
|
| Rate for Payer: United Healthcare VA CCN |
$248.98
|
|
|
X-RAY EXAM NECK SPINE 6/>VWS
|
Facility
|
OP
|
$894.41
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
3207205201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$209.32 |
| Max. Negotiated Rate |
$849.69 |
| Rate for Payer: Aetna of VT Commercial |
$849.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$209.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$396.13
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$209.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$538.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$760.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$724.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$402.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$711.06
|
| Rate for Payer: Cash Price |
$447.20
|
| Rate for Payer: Cash Price |
$447.20
|
| Rate for Payer: Cigna Commercial |
$715.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$715.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$715.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$402.48
|
| Rate for Payer: Multiplan Commercial |
$831.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$760.25
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$402.48
|
| Rate for Payer: United Healthcare Commercial |
$849.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$402.48
|
| Rate for Payer: United Healthcare VA CCN |
$402.48
|
|
|
X-RAY EXAM NECK SPINE 6/>VWS
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
9727205201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$69.09 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna of VT Commercial |
$148.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$139.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$69.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$139.76
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$132.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$126.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$124.02
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$124.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$124.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$124.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$145.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$132.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$70.20
|
| Rate for Payer: United Healthcare Commercial |
$148.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.20
|
| Rate for Payer: United Healthcare VA CCN |
$70.20
|
|
|
X-RAY EXAM OF ANKLE- BILATERAL
|
Facility
|
OP
|
$473.57
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
3207361002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.61 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$209.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$122.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$285.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$383.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$213.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$376.49
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Martins Point Health Care Commercial |
$213.11
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$213.11
|
| Rate for Payer: United Healthcare VA CCN |
$213.11
|
|
|
X-RAY EXAM OF ANKLE- BILATERAL
|
Facility
|
IP
|
$473.57
|
|
|
Service Code
|
CPT 73610
|
| Hospital Charge Code |
3207361002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$350.49 |
| Max. Negotiated Rate |
$449.89 |
| Rate for Payer: Aetna of VT Commercial |
$449.89
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$350.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$402.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$397.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$378.86
|
| Rate for Payer: Cash Price |
$236.78
|
| Rate for Payer: Cigna Commercial |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$378.86
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$378.86
|
| Rate for Payer: Multiplan Commercial |
$440.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$402.53
|
| Rate for Payer: United Healthcare Commercial |
$449.89
|
|
|
X-RAY EXAM SURGICAL SPECIMEN
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 76098
|
| Hospital Charge Code |
9727609801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$57.73 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Aetna of VT Commercial |
$74.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$57.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$57.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$66.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$65.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.40
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$62.40
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$62.40
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$72.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.30
|
| Rate for Payer: United Healthcare Commercial |
$74.10
|
|
