|
XR ELBOW 2 VIEWS
|
Facility
|
OP
|
$440.48
|
|
|
Service Code
|
CPT 73070
|
| Hospital Charge Code |
3207307001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.26 |
| Max. Negotiated Rate |
$418.46 |
| Rate for Payer: Aetna of VT Commercial |
$418.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$92.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$195.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$92.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$265.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$356.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$198.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$350.18
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cigna Commercial |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$198.22
|
| Rate for Payer: Multiplan Commercial |
$409.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.41
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$198.22
|
| Rate for Payer: United Healthcare Commercial |
$418.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$198.22
|
| Rate for Payer: United Healthcare VA CCN |
$198.22
|
|
|
XR ELBOW 2 VIEWS
|
Facility
|
IP
|
$439.45
|
|
|
Service Code
|
CPT 73070 RT
|
| Hospital Charge Code |
32073070RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$325.24 |
| 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 |
$325.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$325.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$373.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$369.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$351.56
|
| 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: Multiplan Commercial |
$408.69
|
| Rate for Payer: MVP Health Care of NY Commercial |
$373.53
|
| Rate for Payer: United Healthcare Commercial |
$417.48
|
|
|
XR ELBOW 2 VIEWS
|
Facility
|
OP
|
$439.45
|
|
|
Service Code
|
CPT 73070 LT
|
| Hospital Charge Code |
32073070LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$92.26 |
| 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 |
$92.26
|
| 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 |
$92.26
|
| 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: 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
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 73080 26
|
| Hospital Charge Code |
9727308001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$33.22 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Aetna of VT Commercial |
$71.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$67.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$33.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$67.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$45.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$63.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$60.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$33.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$59.62
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$60.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$60.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$60.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$33.75
|
| Rate for Payer: Multiplan Commercial |
$69.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$63.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$33.75
|
| Rate for Payer: United Healthcare Commercial |
$71.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.75
|
| Rate for Payer: United Healthcare VA CCN |
$33.75
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$440.48
|
|
|
Service Code
|
CPT 73080
|
| Hospital Charge Code |
3207308001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$326.00 |
| Max. Negotiated Rate |
$418.46 |
| Rate for Payer: Aetna of VT Commercial |
$418.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$370.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.38
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cigna Commercial |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.38
|
| Rate for Payer: Multiplan Commercial |
$409.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.41
|
| Rate for Payer: United Healthcare Commercial |
$418.46
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$440.48
|
|
|
Service Code
|
CPT 73080
|
| Hospital Charge Code |
3207308001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.73 |
| Max. Negotiated Rate |
$418.46 |
| Rate for Payer: Aetna of VT Commercial |
$418.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$195.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$265.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$356.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$198.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$350.18
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cigna Commercial |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$198.22
|
| Rate for Payer: Multiplan Commercial |
$409.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.41
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$198.22
|
| Rate for Payer: United Healthcare Commercial |
$418.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$198.22
|
| Rate for Payer: United Healthcare VA CCN |
$198.22
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$491.41
|
|
|
Service Code
|
CPT 73080 RT
|
| Hospital Charge Code |
32073080RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.73 |
| Max. Negotiated Rate |
$466.84 |
| Rate for Payer: Aetna of VT Commercial |
$466.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$217.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$295.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$417.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$398.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$221.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$390.67
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cigna Commercial |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$221.13
|
| Rate for Payer: Multiplan Commercial |
$457.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$417.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$221.13
|
| Rate for Payer: United Healthcare Commercial |
$466.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.13
|
| Rate for Payer: United Healthcare VA CCN |
$221.13
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$491.41
|
|
|
Service Code
|
CPT 73080 RT
|
| Hospital Charge Code |
32073080RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$363.69 |
| Max. Negotiated Rate |
$466.84 |
| Rate for Payer: Aetna of VT Commercial |
$466.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$363.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$363.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$417.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$412.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$393.13
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cigna Commercial |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.13
|
| Rate for Payer: Multiplan Commercial |
$457.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$417.70
|
| Rate for Payer: United Healthcare Commercial |
$466.84
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 73080 26
|
| Hospital Charge Code |
9727308001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$55.51 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Aetna of VT Commercial |
$71.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$55.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$55.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$63.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$63.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$60.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$60.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$60.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$69.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$71.25
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
CPT 73080 26
|
| Hospital Charge Code |
9727308001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$106.73 |
| Rate for Payer: Aetna of VT Commercial |
$70.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.73
|
| 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 |
$106.73
|
| 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 |
$13.33
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.33
|
| 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 |
$13.33
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$12.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$69.75
|
| 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 ELBOW COMPL MIN 3 VIEWS
|
Facility
|
OP
|
$491.41
|
|
|
Service Code
|
CPT 73080 LT
|
| Hospital Charge Code |
32073080LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.73 |
| Max. Negotiated Rate |
$466.84 |
| Rate for Payer: Aetna of VT Commercial |
$466.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$217.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$106.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$295.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$417.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$398.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$221.13
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$390.67
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cigna Commercial |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.13
|
| Rate for Payer: Martins Point Health Care Commercial |
$221.13
|
| Rate for Payer: Multiplan Commercial |
$457.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$417.70
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$221.13
|
| Rate for Payer: United Healthcare Commercial |
$466.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.13
|
| Rate for Payer: United Healthcare VA CCN |
$221.13
|
|
|
XR ELBOW COMPL MIN 3 VIEWS
|
Facility
|
IP
|
$491.41
|
|
|
Service Code
|
CPT 73080 LT
|
| Hospital Charge Code |
32073080LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$363.69 |
| Max. Negotiated Rate |
$466.84 |
| Rate for Payer: Aetna of VT Commercial |
$466.84
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$363.69
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$363.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$417.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$412.78
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$393.13
|
| Rate for Payer: Cash Price |
$245.71
|
| Rate for Payer: Cigna Commercial |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$393.13
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$393.13
|
| Rate for Payer: Multiplan Commercial |
$457.01
|
| Rate for Payer: MVP Health Care of NY Commercial |
$417.70
|
| Rate for Payer: United Healthcare Commercial |
$466.84
|
|
|
XR ENTIRE SPI 2/3 VW
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 72082 26
|
| Hospital Charge Code |
9727208201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$153.20 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna of VT Commercial |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$175.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$173.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$165.60
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$165.60
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.95
|
| Rate for Payer: United Healthcare Commercial |
$196.65
|
|
|
XR ENTIRE SPI 2/3 VW
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 72082 26
|
| Hospital Charge Code |
9727208201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$91.68 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna of VT Commercial |
$196.65
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$91.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$185.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$124.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$175.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$167.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$93.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$164.56
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$165.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$165.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$93.15
|
| Rate for Payer: Multiplan Commercial |
$192.51
|
| Rate for Payer: MVP Health Care of NY Commercial |
$175.95
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$196.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$93.15
|
| Rate for Payer: United Healthcare VA CCN |
$93.15
|
|
|
XR ENTIRE SPI 2/3 VW
|
Facility
|
OP
|
$509.76
|
|
|
Service Code
|
CPT 72082
|
| Hospital Charge Code |
3207208201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$225.77 |
| Max. Negotiated Rate |
$484.27 |
| Rate for Payer: Aetna of VT Commercial |
$484.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$239.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$225.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$239.66
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$306.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$433.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$412.91
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$229.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$405.26
|
| Rate for Payer: Cash Price |
$254.88
|
| Rate for Payer: Cash Price |
$254.88
|
| Rate for Payer: Cigna Commercial |
$407.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$407.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$407.81
|
| Rate for Payer: Martins Point Health Care Commercial |
$229.39
|
| Rate for Payer: Multiplan Commercial |
$474.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$433.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$229.39
|
| Rate for Payer: United Healthcare Commercial |
$484.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.39
|
| Rate for Payer: United Healthcare VA CCN |
$229.39
|
|
|
XR ENTIRE SPI 2/3 VW
|
Facility
|
IP
|
$509.76
|
|
|
Service Code
|
CPT 72082
|
| Hospital Charge Code |
3207208201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$377.27 |
| Max. Negotiated Rate |
$484.27 |
| Rate for Payer: Aetna of VT Commercial |
$484.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$377.27
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$377.27
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$433.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$428.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$407.81
|
| Rate for Payer: Cash Price |
$254.88
|
| Rate for Payer: Cigna Commercial |
$407.81
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$407.81
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$407.81
|
| Rate for Payer: Multiplan Commercial |
$474.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$433.30
|
| Rate for Payer: United Healthcare Commercial |
$484.27
|
|
|
XR ENTIRE SPI 6/> VW
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT 72084 26
|
| Hospital Charge Code |
9727208401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$119.14 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna of VT Commercial |
$255.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$241.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$119.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$241.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$161.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$228.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$217.89
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$121.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$213.85
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$215.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$215.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$215.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$121.05
|
| Rate for Payer: Multiplan Commercial |
$250.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$228.65
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$121.05
|
| Rate for Payer: United Healthcare Commercial |
$255.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.05
|
| Rate for Payer: United Healthcare VA CCN |
$121.05
|
|
|
XR ENTIRE SPI 6/> VW
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT 72084 26
|
| Hospital Charge Code |
9727208401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$199.09 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna of VT Commercial |
$255.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$199.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$199.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$228.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$225.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$215.20
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$215.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$215.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$215.20
|
| Rate for Payer: Multiplan Commercial |
$250.17
|
| Rate for Payer: MVP Health Care of NY Commercial |
$228.65
|
| Rate for Payer: United Healthcare Commercial |
$255.55
|
|
|
XR ENTIRE SPI 6/> VW
|
Facility
|
IP
|
$697.95
|
|
|
Service Code
|
CPT 72084
|
| Hospital Charge Code |
3207208401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$516.55 |
| Max. Negotiated Rate |
$663.05 |
| Rate for Payer: Aetna of VT Commercial |
$663.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$516.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$516.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$593.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$586.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$558.36
|
| Rate for Payer: Cash Price |
$348.98
|
| Rate for Payer: Cigna Commercial |
$558.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$558.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$558.36
|
| Rate for Payer: Multiplan Commercial |
$649.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$593.26
|
| Rate for Payer: United Healthcare Commercial |
$663.05
|
|
|
XR ENTIRE SPI 6/> VW
|
Facility
|
OP
|
$697.95
|
|
|
Service Code
|
CPT 72084
|
| Hospital Charge Code |
3207208401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$309.12 |
| Max. Negotiated Rate |
$663.05 |
| Rate for Payer: Aetna of VT Commercial |
$663.05
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$342.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$309.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$342.04
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$420.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$593.26
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$565.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$314.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$554.87
|
| Rate for Payer: Cash Price |
$348.98
|
| Rate for Payer: Cash Price |
$348.98
|
| Rate for Payer: Cigna Commercial |
$558.36
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$558.36
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$558.36
|
| Rate for Payer: Martins Point Health Care Commercial |
$314.08
|
| Rate for Payer: Multiplan Commercial |
$649.09
|
| Rate for Payer: MVP Health Care of NY Commercial |
$593.26
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$314.08
|
| Rate for Payer: United Healthcare Commercial |
$663.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$314.08
|
| Rate for Payer: United Healthcare VA CCN |
$314.08
|
|
|
XR EYE FOR FOREIGN BODY
|
Facility
|
OP
|
$485.98
|
|
|
Service Code
|
CPT 70030 LT
|
| Hospital Charge Code |
32070030LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$461.68 |
| Rate for Payer: Aetna of VT Commercial |
$461.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$105.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$215.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$105.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$292.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$413.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$393.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$218.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$386.35
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cigna Commercial |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$388.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.69
|
| Rate for Payer: Multiplan Commercial |
$451.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$413.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$218.69
|
| Rate for Payer: United Healthcare Commercial |
$461.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$218.69
|
| Rate for Payer: United Healthcare VA CCN |
$218.69
|
|
|
XR EYE FOR FOREIGN BODY
|
Facility
|
IP
|
$440.48
|
|
|
Service Code
|
CPT 70030
|
| Hospital Charge Code |
3207003001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$326.00 |
| Max. Negotiated Rate |
$418.46 |
| Rate for Payer: Aetna of VT Commercial |
$418.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$374.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$370.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$352.38
|
| Rate for Payer: Cash Price |
$220.24
|
| Rate for Payer: Cigna Commercial |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$352.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$352.38
|
| Rate for Payer: Multiplan Commercial |
$409.65
|
| Rate for Payer: MVP Health Care of NY Commercial |
$374.41
|
| Rate for Payer: United Healthcare Commercial |
$418.46
|
|
|
XR EYE FOR FOREIGN BODY
|
Facility
|
IP
|
$485.98
|
|
|
Service Code
|
CPT 70030 LT
|
| Hospital Charge Code |
32070030LT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$359.67 |
| Max. Negotiated Rate |
$461.68 |
| Rate for Payer: Aetna of VT Commercial |
$461.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$359.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$359.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$413.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$408.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$388.78
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cigna Commercial |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$388.78
|
| Rate for Payer: Multiplan Commercial |
$451.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$413.08
|
| Rate for Payer: United Healthcare Commercial |
$461.68
|
|
|
XR EYE FOR FOREIGN BODY
|
Facility
|
IP
|
$485.98
|
|
|
Service Code
|
CPT 70030 RT
|
| Hospital Charge Code |
32070030RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$359.67 |
| Max. Negotiated Rate |
$461.68 |
| Rate for Payer: Aetna of VT Commercial |
$461.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$359.67
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$359.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$413.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$408.22
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$388.78
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cigna Commercial |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$388.78
|
| Rate for Payer: Multiplan Commercial |
$451.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$413.08
|
| Rate for Payer: United Healthcare Commercial |
$461.68
|
|
|
XR EYE FOR FOREIGN BODY
|
Facility
|
OP
|
$485.98
|
|
|
Service Code
|
CPT 70030 RT
|
| Hospital Charge Code |
32070030RT
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$461.68 |
| Rate for Payer: Aetna of VT Commercial |
$461.68
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$105.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$215.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$105.28
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$292.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$413.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$393.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$218.69
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$386.35
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cash Price |
$242.99
|
| Rate for Payer: Cigna Commercial |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$388.78
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$388.78
|
| Rate for Payer: Martins Point Health Care Commercial |
$218.69
|
| Rate for Payer: Multiplan Commercial |
$451.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$413.08
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$218.69
|
| Rate for Payer: United Healthcare Commercial |
$461.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$218.69
|
| Rate for Payer: United Healthcare VA CCN |
$218.69
|
|
