|
X-RAY SM INT F-THRU STD
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
9727424801
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$100.65 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Aetna of VT Commercial |
$129.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$100.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$100.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$115.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$114.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$108.80
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna Commercial |
$108.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$108.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$108.80
|
| Rate for Payer: Multiplan Commercial |
$126.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.60
|
| Rate for Payer: United Healthcare Commercial |
$129.20
|
|
|
X-RAY SM INT F-THRU STD
|
Facility
|
IP
|
$720.70
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
3207424801
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$533.39 |
| Max. Negotiated Rate |
$684.66 |
| Rate for Payer: Aetna of VT Commercial |
$684.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$533.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$533.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$612.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$605.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$576.56
|
| Rate for Payer: Cash Price |
$360.35
|
| Rate for Payer: Cigna Commercial |
$576.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$576.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$576.56
|
| Rate for Payer: Multiplan Commercial |
$670.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$612.60
|
| Rate for Payer: United Healthcare Commercial |
$684.66
|
|
|
X-RAY SM INT F-THRU STD
|
Facility
|
OP
|
$720.70
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
3207424801
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$215.08 |
| Max. Negotiated Rate |
$684.66 |
| Rate for Payer: Aetna of VT Commercial |
$684.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$215.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$319.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$215.08
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$433.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$612.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$583.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$324.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$572.96
|
| Rate for Payer: Cash Price |
$360.35
|
| Rate for Payer: Cash Price |
$360.35
|
| Rate for Payer: Cigna Commercial |
$576.56
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$576.56
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$576.56
|
| Rate for Payer: Martins Point Health Care Commercial |
$324.31
|
| Rate for Payer: Multiplan Commercial |
$670.25
|
| Rate for Payer: MVP Health Care of NY Commercial |
$612.60
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$324.31
|
| Rate for Payer: United Healthcare Commercial |
$684.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$324.31
|
| Rate for Payer: United Healthcare VA CCN |
$324.31
|
|
|
X-RAY URETHRA/BLADDER
|
Facility
|
IP
|
$1,424.85
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
3207445002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,054.53 |
| Max. Negotiated Rate |
$1,353.61 |
| Rate for Payer: Aetna of VT Commercial |
$1,353.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,054.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,054.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,211.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,196.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,139.88
|
| Rate for Payer: Cash Price |
$712.42
|
| Rate for Payer: Cigna Commercial |
$1,139.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,139.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,139.88
|
| Rate for Payer: Multiplan Commercial |
$1,325.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,211.12
|
| Rate for Payer: United Healthcare Commercial |
$1,353.61
|
|
|
X-RAY URETHRA/BLADDER
|
Facility
|
OP
|
$1,424.85
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
3207445002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$631.07 |
| Max. Negotiated Rate |
$1,353.61 |
| Rate for Payer: Aetna of VT Commercial |
$1,353.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$1,030.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$631.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$1,030.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$857.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$1,211.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$1,154.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$641.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$1,132.76
|
| Rate for Payer: Cash Price |
$712.42
|
| Rate for Payer: Cash Price |
$712.42
|
| Rate for Payer: Cigna Commercial |
$1,139.88
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$1,139.88
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$1,139.88
|
| Rate for Payer: Martins Point Health Care Commercial |
$641.18
|
| Rate for Payer: Multiplan Commercial |
$1,325.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,211.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$641.18
|
| Rate for Payer: United Healthcare Commercial |
$1,353.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$641.18
|
| Rate for Payer: United Healthcare VA CCN |
$641.18
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
9727422001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$39.42 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$79.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$53.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$72.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$40.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$70.75
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$40.05
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.05
|
| Rate for Payer: United Healthcare VA CCN |
$40.05
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 74283
|
| Hospital Charge Code |
9727422001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$82.77 |
| Max. Negotiated Rate |
$677.47 |
| Rate for Payer: Aetna of VT Commercial |
$83.66
|
| 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 |
$44.50
|
| Rate for Payer: Cash Price |
$44.50
|
| 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 |
$82.77
|
| 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 XM ESOPHAGUS 1CNTRST
|
Facility
|
OP
|
$856.15
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
3207422001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$300.35 |
| Max. Negotiated Rate |
$813.34 |
| Rate for Payer: Aetna of VT Commercial |
$813.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$300.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$379.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$300.35
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$515.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$693.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$385.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$680.64
|
| Rate for Payer: Cash Price |
$428.08
|
| Rate for Payer: Cash Price |
$428.08
|
| Rate for Payer: Cigna Commercial |
$684.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$684.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$684.92
|
| Rate for Payer: Martins Point Health Care Commercial |
$385.27
|
| Rate for Payer: Multiplan Commercial |
$796.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$727.73
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$385.27
|
| Rate for Payer: United Healthcare Commercial |
$813.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$385.27
|
| Rate for Payer: United Healthcare VA CCN |
$385.27
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST
|
Facility
|
IP
|
$856.15
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
3207422001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$633.64 |
| Max. Negotiated Rate |
$813.34 |
| Rate for Payer: Aetna of VT Commercial |
$813.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$633.64
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$633.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$727.73
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$719.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$684.92
|
| Rate for Payer: Cash Price |
$428.08
|
| Rate for Payer: Cigna Commercial |
$684.92
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$684.92
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$684.92
|
| Rate for Payer: Multiplan Commercial |
$796.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$727.73
|
| Rate for Payer: United Healthcare Commercial |
$813.34
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 74220
|
| Hospital Charge Code |
9727422001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$65.87 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna of VT Commercial |
$84.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$65.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$75.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$74.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$71.20
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$71.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$71.20
|
| Rate for Payer: Multiplan Commercial |
$82.77
|
| Rate for Payer: MVP Health Care of NY Commercial |
$75.65
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
|
|
X-RAY XM SM INT 1CNTRST STD
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
9727425001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Aetna of VT Commercial |
$217.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$169.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$169.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$192.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.20
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.20
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$194.65
|
| Rate for Payer: United Healthcare Commercial |
$217.55
|
|
|
X-RAY XM SM INT 1CNTRST STD
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
9727425001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$101.42 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Aetna of VT Commercial |
$217.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$205.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$205.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$137.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.06
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.05
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$194.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.05
|
| Rate for Payer: United Healthcare Commercial |
$217.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.05
|
| Rate for Payer: United Healthcare VA CCN |
$103.05
|
|
|
X-RAY XM SM INT 1CNTRST STD
|
Facility
|
IP
|
$1,108.45
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
3207425001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$820.36 |
| Max. Negotiated Rate |
$1,053.03 |
| Rate for Payer: Aetna of VT Commercial |
$1,053.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$820.36
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$820.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$942.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$931.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$886.76
|
| Rate for Payer: Cash Price |
$554.22
|
| Rate for Payer: Cigna Commercial |
$886.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$886.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$886.76
|
| Rate for Payer: Multiplan Commercial |
$1,030.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$942.18
|
| Rate for Payer: United Healthcare Commercial |
$1,053.03
|
|
|
X-RAY XM SM INT 1CNTRST STD
|
Facility
|
OP
|
$1,108.45
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
3207425001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$363.93 |
| Max. Negotiated Rate |
$1,053.03 |
| Rate for Payer: Aetna of VT Commercial |
$1,053.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$363.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$490.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$363.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$667.29
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$942.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$897.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$498.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$881.22
|
| Rate for Payer: Cash Price |
$554.22
|
| Rate for Payer: Cash Price |
$554.22
|
| Rate for Payer: Cigna Commercial |
$886.76
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$886.76
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$886.76
|
| Rate for Payer: Martins Point Health Care Commercial |
$498.80
|
| Rate for Payer: Multiplan Commercial |
$1,030.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$942.18
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$498.80
|
| Rate for Payer: United Healthcare Commercial |
$1,053.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$498.80
|
| Rate for Payer: United Healthcare VA CCN |
$498.80
|
|
|
X-RAY XM SM INT 1CNTRST STD
|
Professional
|
Both
|
$229.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
9727425001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$36.99 |
| Max. Negotiated Rate |
$215.26 |
| Rate for Payer: Aetna of VT Commercial |
$215.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$131.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$38.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$131.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$51.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$47.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$47.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$42.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.81
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$56.68
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$59.65
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$59.65
|
| Rate for Payer: Martins Point Health Care Commercial |
$36.99
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$36.99
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$36.99
|
| Rate for Payer: United Healthcare Commercial |
$56.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.99
|
| Rate for Payer: United Healthcare VA CCN |
$36.99
|
|
|
X-RAY XM SWLNG FUNCJ C+
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
9727423001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$44.41 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna of VT Commercial |
$57.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$44.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$44.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$48.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$48.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$48.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$55.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.00
|
| Rate for Payer: United Healthcare Commercial |
$57.00
|
|
|
X-RAY XM SWLNG FUNCJ C+
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
9727423001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$26.57 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna of VT Commercial |
$57.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$53.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$26.57
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$53.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$36.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$48.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$47.70
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$48.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$48.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$48.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$55.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$51.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$27.00
|
| Rate for Payer: United Healthcare Commercial |
$57.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.00
|
| Rate for Payer: United Healthcare VA CCN |
$27.00
|
|
|
X-RAY XM SWLNG FUNCJ C+
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
9727423001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$55.80 |
| Max. Negotiated Rate |
$431.83 |
| Rate for Payer: Aetna of VT Commercial |
$56.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$431.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$120.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$431.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$163.44
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$164.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$164.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$134.25
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$164.48
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$181.72
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$187.72
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$187.72
|
| Rate for Payer: Martins Point Health Care Commercial |
$116.74
|
| Rate for Payer: Multiplan Commercial |
$55.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$116.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$116.74
|
| Rate for Payer: United Healthcare Commercial |
$179.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.74
|
| Rate for Payer: United Healthcare VA CCN |
$116.74
|
|
|
X-RAY XM SWLNG FUNCJ C+
|
Facility
|
OP
|
$958.52
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
3207423001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$424.53 |
| Max. Negotiated Rate |
$910.59 |
| Rate for Payer: Aetna of VT Commercial |
$910.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$431.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$424.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$431.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$577.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$814.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$776.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$431.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$762.02
|
| Rate for Payer: Cash Price |
$479.26
|
| Rate for Payer: Cash Price |
$479.26
|
| Rate for Payer: Cigna Commercial |
$766.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$766.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$766.82
|
| Rate for Payer: Martins Point Health Care Commercial |
$431.33
|
| Rate for Payer: Multiplan Commercial |
$891.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$814.74
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$431.33
|
| Rate for Payer: United Healthcare Commercial |
$910.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$431.33
|
| Rate for Payer: United Healthcare VA CCN |
$431.33
|
|
|
X-RAY XM SWLNG FUNCJ C+
|
Facility
|
IP
|
$958.52
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
3207423001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$709.40 |
| Max. Negotiated Rate |
$910.59 |
| Rate for Payer: Aetna of VT Commercial |
$910.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$709.40
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$709.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$814.74
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$805.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$766.82
|
| Rate for Payer: Cash Price |
$479.26
|
| Rate for Payer: Cigna Commercial |
$766.82
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$766.82
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$766.82
|
| Rate for Payer: Multiplan Commercial |
$891.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$814.74
|
| Rate for Payer: United Healthcare Commercial |
$910.59
|
|
|
X-RAY XM UPR GI TRC 1CNTRST
|
Facility
|
IP
|
$948.18
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
3207424002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$701.75 |
| Max. Negotiated Rate |
$900.77 |
| Rate for Payer: Aetna of VT Commercial |
$900.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$701.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$701.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$805.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$796.47
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$758.54
|
| Rate for Payer: Cash Price |
$474.09
|
| Rate for Payer: Cigna Commercial |
$758.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$758.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$758.54
|
| Rate for Payer: Multiplan Commercial |
$881.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$805.95
|
| Rate for Payer: United Healthcare Commercial |
$900.77
|
|
|
X-RAY XM UPR GI TRC 1CNTRST
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
9727424001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$101.42 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Aetna of VT Commercial |
$217.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$205.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$101.42
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$205.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$137.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$185.49
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$103.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$182.06
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$103.05
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$194.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$103.05
|
| Rate for Payer: United Healthcare Commercial |
$217.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103.05
|
| Rate for Payer: United Healthcare VA CCN |
$103.05
|
|
|
X-RAY XM UPR GI TRC 1CNTRST
|
Professional
|
Both
|
$229.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
9727424001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$115.68 |
| Max. Negotiated Rate |
$368.24 |
| Rate for Payer: Aetna of VT Commercial |
$215.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$368.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$119.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$368.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$161.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$160.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$160.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$133.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$160.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$178.65
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$186.18
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$186.18
|
| Rate for Payer: Martins Point Health Care Commercial |
$115.68
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$115.69
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$115.69
|
| Rate for Payer: United Healthcare Commercial |
$177.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.69
|
| Rate for Payer: United Healthcare VA CCN |
$115.69
|
|
|
X-RAY XM UPR GI TRC 1CNTRST
|
Facility
|
OP
|
$948.18
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
3207424002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$368.24 |
| Max. Negotiated Rate |
$900.77 |
| Rate for Payer: Aetna of VT Commercial |
$900.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$368.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$419.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$368.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$570.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$805.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$768.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$426.68
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$753.80
|
| Rate for Payer: Cash Price |
$474.09
|
| Rate for Payer: Cash Price |
$474.09
|
| Rate for Payer: Cigna Commercial |
$758.54
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$758.54
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$758.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$426.68
|
| Rate for Payer: Multiplan Commercial |
$881.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$805.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$426.68
|
| Rate for Payer: United Healthcare Commercial |
$900.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$426.68
|
| Rate for Payer: United Healthcare VA CCN |
$426.68
|
|
|
X-RAY XM UPR GI TRC 1CNTRST
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
9727424001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$217.55 |
| Rate for Payer: Aetna of VT Commercial |
$217.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$169.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$169.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$194.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$192.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$183.20
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$183.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$183.20
|
| Rate for Payer: Multiplan Commercial |
$212.97
|
| Rate for Payer: MVP Health Care of NY Commercial |
$194.65
|
| Rate for Payer: United Healthcare Commercial |
$217.55
|
|
