|
XR LOWER EXTREM INF MIN 2 VWS
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 73592 26
|
| Hospital Charge Code |
9727359201
|
|
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
|
|
|
XR LOWER EXTREM INF MIN 2 VWS
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
CPT 73592
|
| Hospital Charge Code |
3207359201
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of VT Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$0.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Facility
|
IP
|
$597.38
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
3207210001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$442.12 |
| Max. Negotiated Rate |
$567.51 |
| Rate for Payer: Aetna of VT Commercial |
$567.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$442.12
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$442.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$507.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$501.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$477.90
|
| Rate for Payer: Cash Price |
$298.69
|
| Rate for Payer: Cigna Commercial |
$477.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$477.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$477.90
|
| Rate for Payer: Multiplan Commercial |
$555.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$507.77
|
| Rate for Payer: United Healthcare Commercial |
$567.51
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
CPT 72100 26
|
| Hospital Charge Code |
9727210001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$86.59 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Aetna of VT Commercial |
$111.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$86.59
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$86.59
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$99.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$98.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$93.60
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$93.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$93.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$108.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$99.45
|
| Rate for Payer: United Healthcare Commercial |
$111.15
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Professional
|
Both
|
$117.00
|
|
|
Service Code
|
CPT 72100 26
|
| Hospital Charge Code |
9727210001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna of VT Commercial |
$109.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$10.48
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$14.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$16.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$16.15
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$11.70
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$16.15
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$15.45
|
| Rate for Payer: Martins Point Health Care Commercial |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$108.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.17
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$10.17
|
| Rate for Payer: United Healthcare Commercial |
$15.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.17
|
| Rate for Payer: United Healthcare VA CCN |
$10.17
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Facility
|
OP
|
$597.38
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
3207210001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.96 |
| Max. Negotiated Rate |
$567.51 |
| Rate for Payer: Aetna of VT Commercial |
$567.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$264.58
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$359.62
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$507.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$483.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$268.82
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$474.92
|
| Rate for Payer: Cash Price |
$298.69
|
| Rate for Payer: Cash Price |
$298.69
|
| Rate for Payer: Cigna Commercial |
$477.90
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$477.90
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$477.90
|
| Rate for Payer: Martins Point Health Care Commercial |
$268.82
|
| Rate for Payer: Multiplan Commercial |
$555.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$507.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$268.82
|
| Rate for Payer: United Healthcare Commercial |
$567.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$268.82
|
| Rate for Payer: United Healthcare VA CCN |
$268.82
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Professional
|
Both
|
$597.38
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
3207210001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$561.54 |
| Rate for Payer: Aetna of VT Commercial |
$561.54
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$39.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$53.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$51.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$51.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$43.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$51.58
|
| Rate for Payer: Cash Price |
$298.69
|
| Rate for Payer: Cash Price |
$298.69
|
| Rate for Payer: Cigna Commercial |
$58.16
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$61.21
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$61.21
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.96
|
| Rate for Payer: Multiplan Commercial |
$555.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$37.97
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.97
|
| Rate for Payer: United Healthcare Commercial |
$58.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.97
|
| Rate for Payer: United Healthcare VA CCN |
$37.97
|
|
|
XR LUMBOSACRAL 2/3 VIEWS
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
CPT 72100 26
|
| Hospital Charge Code |
9727210001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$51.82 |
| Max. Negotiated Rate |
$111.15 |
| Rate for Payer: Aetna of VT Commercial |
$111.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$104.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$51.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$104.82
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$70.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$99.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$94.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$52.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$93.02
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$93.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$93.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$93.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$52.65
|
| Rate for Payer: Multiplan Commercial |
$108.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$99.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$52.65
|
| Rate for Payer: United Healthcare Commercial |
$111.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.65
|
| Rate for Payer: United Healthcare VA CCN |
$52.65
|
|
|
XR LUMBOSACRAL MIN 4 VIEWS
|
Facility
|
OP
|
$171.00
|
|
|
Service Code
|
CPT 72110 26
|
| Hospital Charge Code |
9727211001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$75.74 |
| Max. Negotiated Rate |
$162.45 |
| Rate for Payer: Aetna of VT Commercial |
$162.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$75.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$153.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$102.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$138.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$76.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$135.94
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$136.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$136.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$76.95
|
| Rate for Payer: Multiplan Commercial |
$159.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.35
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$76.95
|
| Rate for Payer: United Healthcare Commercial |
$162.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.95
|
| Rate for Payer: United Healthcare VA CCN |
$76.95
|
|
|
XR LUMBOSACRAL MIN 4 VIEWS
|
Facility
|
IP
|
$764.13
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
3207211001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$565.53 |
| Max. Negotiated Rate |
$725.92 |
| Rate for Payer: Aetna of VT Commercial |
$725.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$565.53
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$565.53
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$649.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.87
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$611.30
|
| Rate for Payer: Cash Price |
$382.06
|
| Rate for Payer: Cigna Commercial |
$611.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$611.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$611.30
|
| Rate for Payer: Multiplan Commercial |
$710.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$649.51
|
| Rate for Payer: United Healthcare Commercial |
$725.92
|
|
|
XR LUMBOSACRAL MIN 4 VIEWS
|
Professional
|
Both
|
$171.00
|
|
|
Service Code
|
CPT 72110 26
|
| Hospital Charge Code |
9727211001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$171.77 |
| Rate for Payer: Aetna of VT Commercial |
$160.74
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$171.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$12.47
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$171.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$16.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$23.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$23.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.93
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$23.30
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$17.91
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.11
|
| Rate for Payer: Multiplan Commercial |
$159.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.11
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.11
|
| Rate for Payer: United Healthcare Commercial |
$18.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.11
|
| Rate for Payer: United Healthcare VA CCN |
$12.11
|
|
|
XR LUMBOSACRAL MIN 4 VIEWS
|
Facility
|
OP
|
$764.13
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
3207211001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$171.77 |
| Max. Negotiated Rate |
$725.92 |
| Rate for Payer: Aetna of VT Commercial |
$725.92
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$171.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$338.43
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$171.77
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$460.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$649.51
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$618.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$343.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$607.48
|
| Rate for Payer: Cash Price |
$382.06
|
| Rate for Payer: Cash Price |
$382.06
|
| Rate for Payer: Cigna Commercial |
$611.30
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$611.30
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$611.30
|
| Rate for Payer: Martins Point Health Care Commercial |
$343.86
|
| Rate for Payer: Multiplan Commercial |
$710.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$649.51
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$343.86
|
| Rate for Payer: United Healthcare Commercial |
$725.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$343.86
|
| Rate for Payer: United Healthcare VA CCN |
$343.86
|
|
|
XR LUMBOSACRAL MIN 4 VIEWS
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
CPT 72110 26
|
| Hospital Charge Code |
9727211001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$126.56 |
| Max. Negotiated Rate |
$162.45 |
| Rate for Payer: Aetna of VT Commercial |
$162.45
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$126.56
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$126.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$145.35
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$143.64
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$136.80
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$136.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$136.80
|
| Rate for Payer: Multiplan Commercial |
$159.03
|
| Rate for Payer: MVP Health Care of NY Commercial |
$145.35
|
| Rate for Payer: United Healthcare Commercial |
$162.45
|
|
|
XR LUMBSCRL BENDING MIN 6 VWS
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 72114 26
|
| Hospital Charge Code |
9727211401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$144.32 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Aetna of VT Commercial |
$185.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$144.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$144.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$163.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$156.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$165.75
|
| Rate for Payer: United Healthcare Commercial |
$185.25
|
|
|
XR LUMBSCRL BENDING MIN 6 VWS
|
Facility
|
OP
|
$792.04
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
3207211401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$203.52 |
| Max. Negotiated Rate |
$752.44 |
| Rate for Payer: Aetna of VT Commercial |
$752.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$350.79
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$476.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$641.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$356.42
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$629.67
|
| Rate for Payer: Cash Price |
$396.02
|
| Rate for Payer: Cash Price |
$396.02
|
| Rate for Payer: Cigna Commercial |
$633.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.63
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.63
|
| Rate for Payer: Martins Point Health Care Commercial |
$356.42
|
| Rate for Payer: Multiplan Commercial |
$736.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.23
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$356.42
|
| Rate for Payer: United Healthcare Commercial |
$752.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$356.42
|
| Rate for Payer: United Healthcare VA CCN |
$356.42
|
|
|
XR LUMBSCRL BENDING MIN 6 VWS
|
Facility
|
IP
|
$792.04
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
3207211401
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$586.19 |
| Max. Negotiated Rate |
$752.44 |
| Rate for Payer: Aetna of VT Commercial |
$752.44
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$586.19
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$586.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$673.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$665.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$633.63
|
| Rate for Payer: Cash Price |
$396.02
|
| Rate for Payer: Cigna Commercial |
$633.63
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$633.63
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$633.63
|
| Rate for Payer: Multiplan Commercial |
$736.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$673.23
|
| Rate for Payer: United Healthcare Commercial |
$752.44
|
|
|
XR LUMBSCRL BENDING MIN 6 VWS
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 72114 26
|
| Hospital Charge Code |
9727211401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$86.37 |
| Max. Negotiated Rate |
$185.25 |
| Rate for Payer: Aetna of VT Commercial |
$185.25
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$174.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$86.37
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$174.70
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$117.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$165.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$157.95
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$87.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$155.03
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$156.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$156.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$87.75
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$165.75
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$87.75
|
| Rate for Payer: United Healthcare Commercial |
$185.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.75
|
| Rate for Payer: United Healthcare VA CCN |
$87.75
|
|
|
XR LUMBSCRL BENDING MIN 6 VWS
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
CPT 72114 26
|
| Hospital Charge Code |
9727211401
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$13.89 |
| Max. Negotiated Rate |
$203.52 |
| Rate for Payer: Aetna of VT Commercial |
$183.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$19.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$26.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$26.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$26.16
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$20.62
|
| Rate for Payer: Martins Point Health Care Commercial |
$13.89
|
| Rate for Payer: Multiplan Commercial |
$181.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$13.89
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$13.89
|
| Rate for Payer: United Healthcare Commercial |
$21.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.89
|
| Rate for Payer: United Healthcare VA CCN |
$13.89
|
|
|
XR MANDIPLE COMPL MIN 4 VIEWS
|
Facility
|
IP
|
$601.28
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
3207011001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$445.01 |
| Max. Negotiated Rate |
$571.22 |
| Rate for Payer: Aetna of VT Commercial |
$571.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$445.01
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$445.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$511.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$505.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$481.02
|
| Rate for Payer: Cash Price |
$300.64
|
| Rate for Payer: Cigna Commercial |
$481.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$481.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$481.02
|
| Rate for Payer: Multiplan Commercial |
$559.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$511.09
|
| Rate for Payer: United Healthcare Commercial |
$571.22
|
|
|
XR MANDIPLE COMPL MIN 4 VIEWS
|
Facility
|
OP
|
$601.28
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
3207011001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$138.52 |
| Max. Negotiated Rate |
$571.22 |
| Rate for Payer: Aetna of VT Commercial |
$571.22
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$266.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$361.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$511.09
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$487.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$270.58
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$478.02
|
| Rate for Payer: Cash Price |
$300.64
|
| Rate for Payer: Cash Price |
$300.64
|
| Rate for Payer: Cigna Commercial |
$481.02
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$481.02
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$481.02
|
| Rate for Payer: Martins Point Health Care Commercial |
$270.58
|
| Rate for Payer: Multiplan Commercial |
$559.19
|
| Rate for Payer: MVP Health Care of NY Commercial |
$511.09
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$270.58
|
| Rate for Payer: United Healthcare Commercial |
$571.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$270.58
|
| Rate for Payer: United Healthcare VA CCN |
$270.58
|
|
|
XR MANDIPLE COMPL MIN 4 VIEWS
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 70110 26
|
| Hospital Charge Code |
9727011001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$44.73 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna of VT Commercial |
$95.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$90.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$44.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$90.49
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$60.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$81.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$45.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$80.30
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$80.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$80.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$80.80
|
| Rate for Payer: Martins Point Health Care Commercial |
$45.45
|
| Rate for Payer: Multiplan Commercial |
$93.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.85
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$45.45
|
| Rate for Payer: United Healthcare Commercial |
$95.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.45
|
| Rate for Payer: United Healthcare VA CCN |
$45.45
|
|
|
XR MANDIPLE COMPL MIN 4 VIEWS
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 70110 26
|
| Hospital Charge Code |
9727011001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$11.46 |
| Max. Negotiated Rate |
$138.52 |
| Rate for Payer: Aetna of VT Commercial |
$94.94
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$138.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$11.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$138.52
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$16.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$18.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$18.83
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$18.83
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$16.93
|
| Rate for Payer: Martins Point Health Care Commercial |
$11.46
|
| Rate for Payer: Multiplan Commercial |
$93.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.47
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$11.47
|
| Rate for Payer: United Healthcare Commercial |
$17.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.47
|
| Rate for Payer: United Healthcare VA CCN |
$11.47
|
|
|
XR MANDIPLE COMPL MIN 4 VIEWS
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 70110 26
|
| Hospital Charge Code |
9727011001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna of VT Commercial |
$95.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$74.75
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$74.75
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$84.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$80.80
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$80.80
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$80.80
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$80.80
|
| Rate for Payer: Multiplan Commercial |
$93.93
|
| Rate for Payer: MVP Health Care of NY Commercial |
$85.85
|
| Rate for Payer: United Healthcare Commercial |
$95.95
|
|
|
XR MANDIPLE PRTL <4VIEWS
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 70100 26
|
| Hospital Charge Code |
9727010001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.55 |
| 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 |
$69.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$34.55
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$69.88
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$46.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$66.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$63.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$35.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$62.01
|
| 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: Martins Point Health Care Commercial |
$35.10
|
| Rate for Payer: Multiplan Commercial |
$72.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.30
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$35.10
|
| Rate for Payer: United Healthcare Commercial |
$74.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.10
|
| Rate for Payer: United Healthcare VA CCN |
$35.10
|
|
|
XR MANDIPLE PRTL <4VIEWS
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 70100 26
|
| Hospital Charge Code |
9727010001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$131.31 |
| Rate for Payer: Aetna of VT Commercial |
$73.32
|
| 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 |
$8.49
|
| 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 |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.88
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$13.88
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$12.51
|
| Rate for Payer: Martins Point Health Care Commercial |
$8.24
|
| Rate for Payer: Multiplan Commercial |
$72.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.24
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$8.24
|
| Rate for Payer: United Healthcare Commercial |
$12.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.24
|
| Rate for Payer: United Healthcare VA CCN |
$8.24
|
|
