|
XR MANDIPLE PRTL <4VIEWS
|
Facility
|
IP
|
$424.46
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
3207010001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$314.14 |
| Max. Negotiated Rate |
$403.24 |
| Rate for Payer: Aetna of VT Commercial |
$403.24
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$314.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$314.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$360.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$356.55
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$339.57
|
| Rate for Payer: Cash Price |
$212.23
|
| Rate for Payer: Cigna Commercial |
$339.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$339.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$339.57
|
| Rate for Payer: Multiplan Commercial |
$394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$360.79
|
| Rate for Payer: United Healthcare Commercial |
$403.24
|
|
|
XR MANDIPLE PRTL <4VIEWS
|
Facility
|
OP
|
$424.46
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
3207010001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$131.31 |
| Max. Negotiated Rate |
$403.24 |
| Rate for Payer: Aetna of VT Commercial |
$403.24
|
| 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 |
$187.99
|
| 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 |
$255.52
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$360.79
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$343.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$191.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$337.45
|
| Rate for Payer: Cash Price |
$212.23
|
| Rate for Payer: Cash Price |
$212.23
|
| Rate for Payer: Cigna Commercial |
$339.57
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$339.57
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$339.57
|
| Rate for Payer: Martins Point Health Care Commercial |
$191.01
|
| Rate for Payer: Multiplan Commercial |
$394.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$360.79
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$191.01
|
| Rate for Payer: United Healthcare Commercial |
$403.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$191.01
|
| Rate for Payer: United Healthcare VA CCN |
$191.01
|
|
|
XR MANDIPLE PRTL <4VIEWS
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 70100 26
|
| Hospital Charge Code |
9727010001
|
|
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 NASAL BONES COMP MIN 3 VIEW
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 70160 26
|
| Hospital Charge Code |
9727016001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$62.17 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna of VT Commercial |
$79.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$62.17
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$62.17
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$70.56
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$67.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$67.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$67.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$67.20
|
| Rate for Payer: Multiplan Commercial |
$78.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.40
|
| Rate for Payer: United Healthcare Commercial |
$79.80
|
|
|
XR NASAL BONES COMP MIN 3 VIEW
|
Facility
|
IP
|
$471.50
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
3207016001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$348.96 |
| Max. Negotiated Rate |
$447.93 |
| Rate for Payer: Aetna of VT Commercial |
$447.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$348.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$348.96
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$400.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$396.06
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$377.20
|
| Rate for Payer: Cash Price |
$235.75
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$377.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$377.20
|
| Rate for Payer: Multiplan Commercial |
$438.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$400.77
|
| Rate for Payer: United Healthcare Commercial |
$447.93
|
|
|
XR NASAL BONES COMP MIN 3 VIEW
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 70160 26
|
| Hospital Charge Code |
9727016001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna of VT Commercial |
$79.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$75.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$37.20
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$75.26
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$50.57
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$71.40
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$68.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$37.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$66.78
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$67.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$67.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$67.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$78.12
|
| Rate for Payer: MVP Health Care of NY Commercial |
$71.40
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$37.80
|
| Rate for Payer: United Healthcare Commercial |
$79.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.80
|
| Rate for Payer: United Healthcare VA CCN |
$37.80
|
|
|
XR NASAL BONES COMP MIN 3 VIEW
|
Facility
|
OP
|
$471.50
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
3207016001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.41 |
| Max. Negotiated Rate |
$447.93 |
| Rate for Payer: Aetna of VT Commercial |
$447.93
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$208.83
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$128.41
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$283.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$400.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$381.92
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$212.18
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$374.84
|
| Rate for Payer: Cash Price |
$235.75
|
| Rate for Payer: Cash Price |
$235.75
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$377.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$377.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$212.18
|
| Rate for Payer: Multiplan Commercial |
$438.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$400.77
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$212.18
|
| Rate for Payer: United Healthcare Commercial |
$447.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$212.18
|
| Rate for Payer: United Healthcare VA CCN |
$212.18
|
|
|
XR NASAL BONES COMP MIN 3 VIEW
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
CPT 70160 26
|
| Hospital Charge Code |
9727016001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$128.41 |
| Rate for Payer: Aetna of VT Commercial |
$78.96
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$128.41
|
| 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 |
$128.41
|
| 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 |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$11.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$78.12
|
| 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 NECK SOFT TISSUE
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
CPT 70360 26
|
| Hospital Charge Code |
9727036001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$98.07 |
| Rate for Payer: Aetna of VT Commercial |
$73.32
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.07
|
| 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 |
$98.07
|
| 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 |
$13.14
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$13.14
|
| 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 |
$13.14
|
| 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
|
|
|
XR NECK SOFT TISSUE
|
Facility
|
IP
|
$455.48
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
3207036001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$337.10 |
| Max. Negotiated Rate |
$432.71 |
| Rate for Payer: Aetna of VT Commercial |
$432.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$337.10
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$337.10
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$387.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$382.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$364.38
|
| Rate for Payer: Cash Price |
$227.74
|
| Rate for Payer: Cigna Commercial |
$364.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$364.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$364.38
|
| Rate for Payer: Multiplan Commercial |
$423.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$387.16
|
| Rate for Payer: United Healthcare Commercial |
$432.71
|
|
|
XR NECK SOFT TISSUE
|
Facility
|
OP
|
$455.48
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
3207036001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.07 |
| Max. Negotiated Rate |
$432.71 |
| Rate for Payer: Aetna of VT Commercial |
$432.71
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$98.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$201.73
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$98.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$274.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$387.16
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$368.94
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$204.97
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$362.11
|
| Rate for Payer: Cash Price |
$227.74
|
| Rate for Payer: Cash Price |
$227.74
|
| Rate for Payer: Cigna Commercial |
$364.38
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$364.38
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$364.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$204.97
|
| Rate for Payer: Multiplan Commercial |
$423.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$387.16
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$204.97
|
| Rate for Payer: United Healthcare Commercial |
$432.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$204.97
|
| Rate for Payer: United Healthcare VA CCN |
$204.97
|
|
|
XR NECK SOFT TISSUE
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 70360 26
|
| Hospital Charge Code |
9727036001
|
|
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 NECK SOFT TISSUE
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 70360 26
|
| Hospital Charge Code |
9727036001
|
|
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 ORBITS COMPL MIN 4 VIEWS
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 70200 26
|
| Hospital Charge Code |
9727020001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$53.15 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna of VT Commercial |
$114.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$107.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$53.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$107.51
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$97.20
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$54.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$95.40
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$96.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$96.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$96.00
|
| Rate for Payer: Martins Point Health Care Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$111.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$102.00
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$54.00
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.00
|
| Rate for Payer: United Healthcare VA CCN |
$54.00
|
|
|
XR ORBITS COMPL MIN 4 VIEWS
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
3207020001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$150.09 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna of VT Commercial |
$491.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$150.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$228.98
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$150.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$311.23
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$439.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$418.77
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$232.65
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$411.01
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$413.60
|
| Rate for Payer: Martins Point Health Care Commercial |
$232.65
|
| Rate for Payer: Multiplan Commercial |
$480.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$439.45
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$232.65
|
| Rate for Payer: United Healthcare Commercial |
$491.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$232.65
|
| Rate for Payer: United Healthcare VA CCN |
$232.65
|
|
|
XR ORBITS COMPL MIN 4 VIEWS
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
3207020001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$382.63 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna of VT Commercial |
$491.15
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$382.63
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$382.63
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$439.45
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$434.28
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$413.60
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$413.60
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$413.60
|
| Rate for Payer: Multiplan Commercial |
$480.81
|
| Rate for Payer: MVP Health Care of NY Commercial |
$439.45
|
| Rate for Payer: United Healthcare Commercial |
$491.15
|
|
|
XR ORBITS COMPL MIN 4 VIEWS
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 70200 26
|
| Hospital Charge Code |
9727020001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$150.09 |
| Rate for Payer: Aetna of VT Commercial |
$112.80
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$150.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$13.14
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$150.09
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$17.86
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$21.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$21.08
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$14.67
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$21.08
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: Martins Point Health Care Commercial |
$12.76
|
| Rate for Payer: Multiplan Commercial |
$111.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$12.76
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$12.76
|
| Rate for Payer: United Healthcare Commercial |
$19.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.76
|
| Rate for Payer: United Healthcare VA CCN |
$12.76
|
|
|
XR ORBITS COMPL MIN 4 VIEWS
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 70200 26
|
| Hospital Charge Code |
9727020001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$88.81 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna of VT Commercial |
$114.00
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$88.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$88.81
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$102.00
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$96.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$96.00
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$96.00
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$111.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$102.00
|
| Rate for Payer: United Healthcare Commercial |
$114.00
|
|
|
XR OSSEIOUS SURVEY INFANT
|
Professional
|
Both
|
$314.00
|
|
|
Service Code
|
CPT 77076 26
|
| Hospital Charge Code |
9727707601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$31.66 |
| Max. Negotiated Rate |
$321.81 |
| Rate for Payer: Aetna of VT Commercial |
$295.16
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$321.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$32.61
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$321.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$44.32
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$53.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$53.84
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$36.41
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$53.84
|
| Rate for Payer: Cash Price |
$157.00
|
| Rate for Payer: Cash Price |
$157.00
|
| Rate for Payer: Cigna Commercial |
$47.61
|
| Rate for Payer: Martins Point Health Care Commercial |
$31.67
|
| Rate for Payer: Multiplan Commercial |
$292.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$44.96
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$31.66
|
| Rate for Payer: United Healthcare Commercial |
$48.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.66
|
| Rate for Payer: United Healthcare VA CCN |
$31.66
|
|
|
XR OSSEIOUS SURVEY INFANT
|
Facility
|
OP
|
$314.00
|
|
|
Service Code
|
CPT 77076 26
|
| Hospital Charge Code |
9727707601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$139.07 |
| Max. Negotiated Rate |
$298.30 |
| Rate for Payer: Aetna of VT Commercial |
$298.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$281.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$139.07
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$281.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$189.03
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$266.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$254.34
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$141.30
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$249.63
|
| Rate for Payer: Cash Price |
$157.00
|
| Rate for Payer: Cigna Commercial |
$251.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$251.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$251.20
|
| Rate for Payer: Martins Point Health Care Commercial |
$141.30
|
| Rate for Payer: Multiplan Commercial |
$292.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$266.90
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$141.30
|
| Rate for Payer: United Healthcare Commercial |
$298.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.30
|
| Rate for Payer: United Healthcare VA CCN |
$141.30
|
|
|
XR OSSEIOUS SURVEY INFANT
|
Facility
|
OP
|
$851.91
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
3207707601
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$321.81 |
| Max. Negotiated Rate |
$809.31 |
| Rate for Payer: Aetna of VT Commercial |
$809.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$321.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$377.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$321.81
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$512.85
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$724.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$690.05
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$383.36
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$677.27
|
| Rate for Payer: Cash Price |
$425.96
|
| Rate for Payer: Cash Price |
$425.96
|
| Rate for Payer: Cigna Commercial |
$681.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$681.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$681.53
|
| Rate for Payer: Martins Point Health Care Commercial |
$383.36
|
| Rate for Payer: Multiplan Commercial |
$792.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$724.12
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$383.36
|
| Rate for Payer: United Healthcare Commercial |
$809.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$383.36
|
| Rate for Payer: United Healthcare VA CCN |
$383.36
|
|
|
XR OSSEIOUS SURVEY INFANT
|
Facility
|
IP
|
$851.91
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
3207707601
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$630.50 |
| Max. Negotiated Rate |
$809.31 |
| Rate for Payer: Aetna of VT Commercial |
$809.31
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$630.50
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$630.50
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$724.12
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$715.60
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$681.53
|
| Rate for Payer: Cash Price |
$425.96
|
| Rate for Payer: Cigna Commercial |
$681.53
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$681.53
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$681.53
|
| Rate for Payer: Multiplan Commercial |
$792.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$724.12
|
| Rate for Payer: United Healthcare Commercial |
$809.31
|
|
|
XR OSSEIOUS SURVEY INFANT
|
Facility
|
IP
|
$314.00
|
|
|
Service Code
|
CPT 77076 26
|
| Hospital Charge Code |
9727707601
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$232.39 |
| Max. Negotiated Rate |
$298.30 |
| Rate for Payer: Aetna of VT Commercial |
$298.30
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$232.39
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$232.39
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$266.90
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$263.76
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$251.20
|
| Rate for Payer: Cash Price |
$157.00
|
| Rate for Payer: Cigna Commercial |
$251.20
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$251.20
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$251.20
|
| Rate for Payer: Multiplan Commercial |
$292.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$266.90
|
| Rate for Payer: United Healthcare Commercial |
$298.30
|
|
|
XR OSSEOUS SURVERY COMPL
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
CPT 77075 26
|
| Hospital Charge Code |
9727707501
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$24.72 |
| Max. Negotiated Rate |
$318.95 |
| Rate for Payer: Aetna of VT Commercial |
$245.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$318.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$318.95
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange |
$34.61
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$41.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$41.01
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage |
$28.43
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$41.01
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$37.54
|
| Rate for Payer: Martins Point Health Care Commercial |
$24.72
|
| Rate for Payer: Multiplan Commercial |
$242.73
|
| Rate for Payer: MVP Health Care of NY Commercial |
$35.10
|
| Rate for Payer: MVP Health Care of NY Medicare Advantage |
$24.72
|
| Rate for Payer: United Healthcare Commercial |
$38.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.72
|
| Rate for Payer: United Healthcare VA CCN |
$24.72
|
|
|
XR OSSEOUS SURVERY COMPL
|
Facility
|
IP
|
$972.99
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
3207707501
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$720.11 |
| Max. Negotiated Rate |
$924.34 |
| Rate for Payer: Aetna of VT Commercial |
$924.34
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial |
$720.11
|
| Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange |
$720.11
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Commercial |
$827.04
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care |
$817.31
|
| Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan |
$778.39
|
| Rate for Payer: Cash Price |
$486.50
|
| Rate for Payer: Cigna Commercial |
$778.39
|
| Rate for Payer: Harvard Pilgrim Health Care HMO |
$778.39
|
| Rate for Payer: Harvard Pilgrim Health Care PPO |
$778.39
|
| Rate for Payer: Multiplan Commercial |
$904.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$827.04
|
| Rate for Payer: United Healthcare Commercial |
$924.34
|
|
